Treating Alcohol and Drug Abuse : An Evidence Based Review

Treating Alcohol and Drug Abuse An Evidence Based Review Edited by M. Berglund, S. Thelander, E. Jonsson Treating Alco...

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Treating Alcohol and Drug Abuse An Evidence Based Review Edited by M. Berglund, S. Thelander, E. Jonsson

Treating Alcohol and Drug Abuse. Edited by M. Berglund, S. Thelander, E. Jonsson Copyright c 2003 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim ISBN: 3-527-30682-X

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Treating Alcohol and Drug Abuse An Evidence Based Review

Edited by Mats Berglund, Sten Thelander, Egon Jonsson

Editors Prof. Dr. Mats Berglund University Hospital MAS Alcohol and Drug Clinic S-20502 Malmö Sweden Dr. Sten Thelander Project Manager, SBU Box 5650 S-11486 Stockholm Sweden Prof. Dr. Egon Jonsson Executive Director, SBU Box 5650 S-11486 Stockholm Sweden

This book was carefully produced. Nevertheless, editors, authors and publisher do not warrant the information contained therein to be free of errors. Readers are advised to keep in mind that statements, data, illustrations, procedural details or other items may inadvertently be inaccurate. Library of Congress Card No.: applied for A catalogue record for this book is available from the British Library. Bibliographic information published by Die Deutsche Bibliothek Die Deutsche Bibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data is available in the Internet at http://dnb.ddb.de. c 2003 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim All rights reserved (including those of translation in other languages). No part of this book may be reproduced in any form – nor transmitted or translated into a machine language without written permission from the publishers. Registered names, trademarks, etc. used in this book, even when not specifically marked as such, are not to be considered unprotected by law. Printed in the Federal Republic of Germany. Printed on acid-free paper.

Composition Hagedorn Kommunikation, Viernheim Printing betz-druck GmbH, Darmstadt Bookbinding Litges & Dopf Buchbinderei GmbH, Heppenheim Cover Design Grafik Design Schulz, Fußgönheim ISBN

3-527-30682-X

Evidence Preface

Preface (Background and Methodology) Evidence Based Medicine and the Swedish Council on Technology Assessment in Health Care

Like many other governments in the early 1980s, the government of Sweden faced an accelerating number of emerging technologies and medical innovations that were being incorporated into its health care system. The consequent (and alarming) increase in the cost of health care became an urgent concern. This situation led in 1987 to the founding of the Swedish Council on Technology Assessment in Health Care (the official acronym is SBU). As its name implies, SBU assesses the technologies and methods used in providing health services. These assessments are systematic evaluations that summarize the medical and scientific literature from around the world. Leading experts, mostly from Sweden but also from other countries, are involved in conducting and reviewing the SBU assessment projects. While striving to keep the needs of the patient (the whole patient) at the center of health care planning, each assessment project investigates not only the medical aspects of a treatment option, but also its economic, social, and ethical aspects. Assessment projects aim to identify the most effective and, if possible, the most cost-effective interventions. They also aim to identify the technologies already in use that are not adequately supported by scientific evidence. Assessment findings can be used by clinicians, administrators, and policy makers to assure the most appropriate allocation of the limited resources available to health care. A Project Group comprising 13 investigators, including a statistician, was selected to assess the wealth of scientific literature on the treatment of alcohol and drug problems. The Group performed the initial, integrated literature search with guidance from a specially trained librarian. A checklist for rating quality was developed, based on already available instruments. Meta-analytic techniques were optional, but were applied where possible. In most areas it was possible to draw conclusions based solely on randomized controlled trials (RCTs). Based on the completed reviews and guided by comments from several external reviewers, the Chair of the Project Group and SBU staff members wrote an Executive Summary. The SBU Board of Directors and the SBU Scientific Advisory Committee approved the Summary and Conclusions.

V

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Preface

The scope of the SBU review was extremely comprehensive, covering all clinically relevant RCTs in the fields of alcohol and narcotics. Because of the large number of studies, the detailed type of analysis often found in a Cochrane review of a small and narrowly defined area was not possible.

Quality Assessment

Many methods for assessing the quality of studies have been described, ranging from a few basic aspects to elaborate scales with weighting of the individual items. The purpose of quality rating is to identify sources of bias, which could endanger the results of the study. In many cases, aspects of external validity or generalizability are also included in the quality assessment. The empirical value of quality assessment remains uncertain. Some, but not all, studies have found larger effects when randomization was unreliable, blinding was not accomplished, or noncompleters were unaccounted for. Our checklist was developed on the basis of already available checklists, and included items related to both internal and external validity. Each item could score from 1 to 3, with 3 representing the highest quality. A scoring manual was also developed. The maximum score possible was 30 for individual studies and 33 for multicenter studies. The summary score was primarily used as a qualitative measure, and was never used to exclude studies or to give them different weights in the meta-analyses. Because of time constraints, not all studies were read by two independent readers. This is a potential source of bias. In an attempt to reduce this risk, studies selected via a random sample were read by each member of the Project Group, and a consensus was reached concerning ratings of the different items. Most large and new studies were read by several members of the Project Group.

Meta-analytic Procedures

The use of formal meta-analytic procedures was optional, but was to a considerable extent related to the quantity or quality of studies in the areas reviewed. Meta-analyses were performed in the chapters on psychosocial treatment of alcohol dependence and drug dependence and in those on medication for drug dependence, and on some treatments in the chapter on medication for alcohol dependence. Metaanalyses were not performed in the other chapters. We decided to use the standardized mean difference effect sizes as the general outcome measure throughout the entire report, with very few exceptions. The Hedges correction was used (Hedges and Olkin, 1985) to adjust for small sample size bias. The correction factor is 1–[3/(4n–9)], where n equals the total number of participants. Although no strict clinical interpretation of effect sizes is agreed upon, many apply the convention that 0.2 is a small but relevant effect, 0.5 a moderate effect, and 0.8 a large effect.

Preface

For categorical data we first calculated the odds ratio and then transformed it to d according to Shadish and Haddock (1994). Intention-to-treat analysis (ITT) was applied when the primary outcome was calculated. We defined intention-to-treat as all patients randomized. If intention-totreat results were not available, an attempt was made to recalculate the figures (presented in the individual study section). If an ITT analysis was not possible, we used the results of the completers analysis. Outcome variables as similar as possible were used in the separate chapters of the analysis. The outcomes could vary among the chapters and also for different analyses within a chapter. The main variables were the abstinence rate and the number of abstinence days in the alcohol section. Some analyses used the rate of return to heavy drinking and number of heavy drinking days. In the chapters on drug dependence, two outcome variables were used concurrently. Those variables were abuse and retention rate in treatment programs. In most studies, especially the older studies on alcohol, no primary outcome variable was defined. Generally, the choice of outcome variables was made as similar as possible for the different studies in the separate analyses. In most of the studies that used pharmacological treatment, the outcome was defined as that at the end of the treatment period. Analysis was generally performed without attempts to standardize the duration of treatment. The psychosocial treatment studies usually used outcome after a follow-up period. The period was chosen to be as constant as possible for the different studies in the separate analyses. Aggregated effect sizes were computed with the Comprehensive Meta-analysis Software Program (Borenstein et al., 1998). The different meta-analytic calculations were tested for heterogeneity using the same program. If the studies were homogenous, a fixed model was used. If, however, heterogeneity was present, a search for moderator effects was initially performed. If no obvious moderator could be identified, the results of a random-effects model were presented in addition to those from the fixed-effects model. The moderators were tested for significances using the same meta-analytic program. Publication bias is always a reason for concern. The simple, but not completely reliable, funnel-plot methodology was used in the meta-analyses of psychosocial interventions for drug dependence. No signs of publication bias were evident in the opiate studies, and a slight tendency was found in the cocaine studies.

English Edition

The English language edition of the report presented here includes papers that were published after the Project Group had completed their literature search for the Swedish edition. Most of the chapters include the new papers as an addendum. In the chapter on pharmacotherapy of alcohol dependence, however, the new papers have been integrated in the text. The meta-analytic methodology has been refined and developed (Borenstein et al., 1998). Some inadequate calculations

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of effect sizes in the original Swedish version have been corrected. Because of the lack of evidence for cost-effectiveness of particular interventions, a section on economic aspects that appeared in the Swedish version has been excluded in the English edition.

References

Borenstein M, Rothstein H. Comprehensive Meta Analysis. A Computer Program for Systematic Reviews. Biostatä, Englewood, 1998. Hedges LV, Olkin I. Statistical methods for meta-analysis. Orlando, Fl., Academic Press, 1985. Shadish WR, Haddock KC. Combining estimates of effect size. In: Cooper H, & Hedges EV (Eds): The handbook of research synthesis. New York, Russel Sage Foundations pp. 26-281, 1994.

Treating Foreword

Treating Alcohol and Drug Abuse – An Evidence Based Review Foreword by Henry R. Kranzler, M. D. It is a challenge to provide a suitable introduction for a work as ambitious as that undertaken here by The Swedish Council on Technology Assessment in Health Care (SBU). The Council and the contributors to this volume are to be commended for their diligence, hard work, and courage in bringing to fruition an effort of this magnitude. The numerous scientific reviewers of the work also deserve credit for their important contribution. For much of its history, the field of alcohol and drug abuse treatment has been steeped in lore and tradition. Empirical research has not been seen as a necessary basis for clinical practice in this area. During the past decade, however, interest in evidence-based practice in medicine generally and the increasing “medicalization” of substance abuse treatment have led to a greater emphasis on the scientific method to generate practice guidelines for the diagnosis and treatment of addictive disorders. Most notably, the randomized clinical trial has become the agreed-upon standard in substance abuse treatment research. In large measure, however, evidence-based treatments for substance use disorders have lagged behind the treatment of other disorders, including psychiatric disorders such as schizophrenia and mood disorders. The current volume, which is comprehensive and detailed, should help to narrow this gap. The volume, consisting of 10 chapters, covers a full range of topics in alcohol and drug abuse treatment. It begins with a review of interventions for hazardous drinking. The pharmacological treatment of alcohol withdrawal is covered next. Separate chapters on the psychosocial and pharmacological treatment of alcoholism follow. A chapter on the long-term course of alcohol and drug dependence provides the transition to four chapters on the treatment of drug dependence. As is true for alcohol dependence, there is a separate chapter on psychosocial treatments for drug dependence. Three chapters on the pharmacological treatment of drug dependence (i.e., treatment of opioid withdrawal, treatment of opioid dependence and treatment of cocaine dependence) follow. A final chapter reviews the literature on substance abuse during pregnancy and the neonatal period. Three appendices provide a list of the contributors and scientific reviewers, the criteria used to rate the quality of the articles reviewed and guidelines employed to estimate effect size.

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Foreword

This volume is an English translation of the work that was originally published in Swedish. Not all reviewers of the Swedish version of this magnum opus agree that the volume is as important a contribution as I believe it to be. Poikolainen (2002) criticized the Swedish version of this work as containing errors that cast doubt on the validity of the main findings. Although many of the problems attributed to the Swedish version of the review have been corrected in the English translation, the impact on the main findings of those corrections was not great, arguing against the criticism leveled by Poikolainen. I believe that this volume should be required reading for anyone who seeks to be knowledgeable in the treatment of alcohol and drug dependence. Although the summary and conclusions can be read rather easily, it is clear that the overview provided by that brief section serves only to orient the reader. The full measure of this work is in the detailed information that is contained in the 10 chapters that follow.

Reference

Poikolainen, K. A nice try that fails: The Swedish Council on Technology Assessment in Health Care (SBU) evaluation of the effect of treatment of alcohol and drug problems: The epidemiologist’s view. Alcohol & Alcoholism 37:416–418, 2002.

Contents

Contents Preface V Foreword IX 1

1.1 1.2 1.3 1.3.1 1.3.2 1.3.3 1.3.4 1.3.5 1.4 1.4.1 1.4.2 1.4.3 1.4.4 1.4.5 1.5 1.5.1 1.5.2 1.6 1.6.1 1.7 1.8 1.9

Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems 1 Introduction 1 Aim 2 Methods 2

Selection of Studies, Inclusion and Exclusion Criteria 2 Search Strategy 2 Outcome Measures 3 Rating Scientific Quality 3 Analyzing the Results 3 Results 4 Literature Search 4 Previous Reviews and Meta-Analysis 4 Randomized and Controlled Studies 5 Studies with Positive Outcome (Measures) Presented in Order of Quality 16 Studies without Significant Effects, Presented in Order of Quality 23 Analysis of the Overall Results of the Reviewed Studies 26 Studies with a Positive Outcome 26 Studies which Showed No Effects 36 Important Aspects of Brief Intervention 36 Analysis of Special Groups 36 Problems with Dropout in Studies 37 Problems with Implementation 37 Summary 38 Glossary 38 References 39


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2 2.1 2.1.1 2.1.2 2.1.3 2.1.4 2.1.5 2.1.6 2.1.7 2.1.8 2.2 2.2.1 2.2.2 2.2.3 2.3 2.3.1

2.3.2 2.4 2.5 2.5.1 2.5.2 2.5.3 2.5.4 2.5.5 2.5.6 2.5.7 2.6 2.6.1 2.7 2.8 2.9 2.10 2.11 2.12 2.13 2.14

3 3.1 3.2 3.2.1 3.2.2 3.2.3

Psychosocial Treatment for Alcohol Dependence 43

Introduction 43 Earlier Reviews 43 Assessing the Effects of Different Methods 43 Methodological Deficiencies and Problems 45 Treatment Methods 45 Treatment Effects 47 Questions Addressed 48 Intensity and Aftercare 49 Subgroups of Alcohol Dependence 49 Method and Material 50 Search Strategies 50 Result Protocol 50 Meta-analysis 51 Results 51 Does psychosocial treatment have any effect? Comparisons with no treatment 51 Are some methods superior to others? 54 Motivational Methodology 54 Methods Specifically Aimed at Changing the Drinking Problem Itself 56 Cognitive Behavioral Therapy (CBT) 56 Broad Spectrum Treatment with CBT Focus 57 CRA Treatment – Community Reinforcement Approach 59 Self-control Training 61 Cue Exposure 62 Other 63 Twelve-Step Treatment 63 Methods Aimed at the Factors Behind Alcohol Dependence 65 Dynamically Oriented Treatments 65 Standard Treatment 67 Marital Therapies and Interventions Focused on Family Members 69 Studies Showing Matching Results 70 Comparing the Intensity of Treatment and Aftercare 73 Subgroups of Alcohol-Dependent Patients 75 Therapist Factors 78 Gender-related Effects 79 Renewed Literature Search 82 References 178 Pharmacotherapy for Alcohol Withdrawal Syndrome 189

Introduction 189 Methods 190 Selection Criteria 190 Diagnostic Criteria and Outcome Measures 190 Search Strategy 190

Contents

3.2.4 3.3 3.3.1 3.3.1.1 3.3.1.2 3.3.1.3 3.3.1.4 3.3.1.5 3.3.1.6 3.3.1.7 3.3.1.8 3.3.1.9 3.3.2 3.3.2.1 3.3.2.2 3.3.2.3 3.3.2.4 3.3.2.5 3.3.2.6 3.4 3.5

4 4.1 4.2 4.2.1 4.2.2 4.2.3 4.3 4.3.1 4.3.2 4.4 4.5 4.6 4.6.1 4.6.2 4.6.3 4.6.4 4.6.5 4.6.6 4.6.7 4.6.8 4.6.9 4.7

Results 191 Included Studies 191 Treatment of Alcohol Withdrawal 191 Benzodiazepines 191 Chlormethiazole and Anti-Epileptics 204 Imidazoline Agonists 214 Beta-Receptor Antagonists 220 Nitrous Oxide 221 Thiamine 221 Psychological Treatment 228 Other Treatment 228 Meta-analyses and Reviews 229 Treatment of Delirium Tremens 229 Barbiturates 229 Benzodiazepines 234 Chlormethiazole 234 Imidazoline Agonists 234 Other Treatment 235 Meta-analyses 235 Discussion 235 Summary 239 References 240 Pharmacotherapy for Alcohol Dependence 247

Introduction 247 Methods 248 Search Strategies 248 Complementary Search 248 Unpublished Studies 249 Analytical Principles 249 Categorization 249 Target Group and Treatment Goals 249 Overview of Tables 250 Overview of Included Studies 252 Results 252 Aversive Agents 252 Antipsychotic Drugs 260 Dopamine Agonists 260 SSRI Agents 261 Other Agents with Effect on the 5-HT System 268 Acamprosate 268 Naltrexone and Nalmefene 269 Other Agents 289 Lithium 289 Comorbidity 294

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4.7.1 4.8 4.8.1 4.8.2 4.8.3 4.8.4 4.9

5 5.1 5.2 5.2.1 5.2.2 5.2.3 5.3 5.4 5.4.1 5.5 5.6 5.7

6 6.1 6.2 6.2.1 6.2.1.1 6.2.1.2 6.2.1.3 6.2.2 6.2.3 6.2.4 6.3 6.3.1 6.3.2 6.3.3 6.4 6.4.1 6.4.2 6.4.3 6.4.4 6.4.5 6.4.6 6.5

Anti-Depressive Treatment and Psychiatric Comorbidity (Depression) 294 Discussion 295 Acamprosate and Naltrexone 295 Aversive Agents 295 Other Agents 302 Treatment of Comorbid Conditions 302 Conclusions 302 Reference 303 The Long-Term Course in Alcohol and Drug Dependence 313

Introduction 313 Methods 314 Search Strategies 314 Inclusion Criteria 314 Search Results 314 Epidemiological Studies 315 Longitudinal Clinical Trials 317 Long-Term Course in Alcohol Dependence 317 Long-Term Course in Heroin Dependence 319 Alcohol and Drug Abuse as a Chronic Condition 321 Conclusions 322 References 323 Psychosocial Treatment for Drug Dependence 325

Introduction 325 Psychosocial Methods – a Review 326 Supportive Treatment Methods 326 Institutional Treatment 327 Structure-Enhancing Interventions 328 Other Supportive Intervention and Treatment Methods 328 Re-educative Methods 329 More Extensive Psychotherapy 331 Reconstructive Therapy 333 Research Considerations 335 Observational Studies 335 Questions 335 Theoretical Approach 335 Methods 336 Search Strategies 336 Representativity 336 Publication Bias 337 Quality Rating 338 Classifying and Synthesizing the Material 338 Data Analysis 339 Results 340

Contents

6.5.1 6.5.1.1 6.5.1.2 6.5.1.3 6.5.2 6.5.2.1 6.5.2.2 6.5.2.3 6.5.3 6.5.3.1 6.5.3.2 6.5.3.3 6.5.4 6.5.4.1 6.5.4.2 6.5.4.3 6.5.4.4 6.5.5 6.5.5.1 6.5.5.2 6.5.6 6.5.6.1 6.5.6.2 6.5.6.3 6.5.6.4 6.5.7 6.5.7.1 6.5.7.2 6.6

7 7.1 7.2 7.3 7.3.1 7.3.1.1 7.3.1.2 7.3.1.3 7.3.1.4 7.3.1.5 7.3.2

Meta-analysis of Treatment for Opiate Dependence 340 Reduction of Heroin Abuse 341 Retention in Opiate Studies 344 Conclusions 344 Meta-analysis of Interventions in Cocaine Dependence 344 Reduction of Cocaine Abuse 345 Retention in Cocaine Studies 350 Conclusions 351 Limitations in Interpreting the Results of Meta-analyses 351 Combination Therapy with Antidepressants and Cognitive Therapy in Cocaine Dependence 351 Meta-analysis of Interventions in Cannabis Dependence 354 Conclusions 354 Randomized Studies of Institutional Treatment 355 Meta-analysis of Institutional Treatment with Opiate Abuse as Outcome Measure 355 Meta-analysis of Institutional Treatment with Reduced Opiate and Cocaine Abuse as Outcome Measure 355 Retention in Institutional Treatment 358 Conclusion 359 Structure-enhancing Interventions 359 Treating Mentally Ill and Homeless Abusers 362 Conclusions 363 Before-and-After Changes in Treatment 363 Studies of Opiate Abuse 363 Studies of Cocaine Abuse 363 Studies of Institutional Treatment 368 Conclusions 368 Effects on Factors other than Abuse 369 Treatment Focus 369 Limitations of Randomized Treatment Studies 369 Appendix 369 References 404 Pharmacotherapy for Opioid Withdrawal 415

Background 415 Principles of Withdrawal Treatment 416 Non-Rapid 417 Adrenergic Agonists Clonidine (unless otherwise stated) versus 417 Placebo 417 Methadone 417 Bubrenorphine 418 Doxepin 418 Other Adrenergic Agonists 418 Opioid Agonists Methadone versus 420

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7.3.2.1 7.3.2.2 7.3.2.3 7.3.2.4 7.3.2.5 7.4 7.4.1 7.4.1.1 7.4.1.2 7.4.1.3 7.4.2 7.4.2.1 7.5 7.5.1 7.5.2 7.5.3 7.6 7.7 7.8 7.8.1 7.8.1.1 7.8.1.2 7.8.1.3 7.8.2 7.8.3 7.8.4 7.8.5

8 8.1 8.2 8.2.1 8.2.2 8.2.3 8.2.4 8.2.4.1 8.2.4.2 8.3 8.3.1

Placebo 420 Bubrenorphine 420 Propoxyphene 420 Chlordiazepoxide 420 Summary (Non-Rapid) 421 Rapid 438 Adrenergic Agonist + Opioid Antagonists Clonidine versus Clonidine + naltrexone/naloxone versus 438 Placebo 438 Buprenorphine 438 Methadone 438 Partial opioid agonist + opioid antagonist + adrenergic agonist 439 Summary (Rapid) 439 Ultra-Rapid (Adrenergic agonist) + opioid antagonist under anesthesia, or under different levels of sedation 448 Naloxone versus Placebo 449 (Clonidine) + Naloxone/Naltrexone under Light Sedation versus Deep Sedation 448 Summary (Ultra-Rapid) 448 Reviews 449 Conclusion 452 Reference 453 Appendix 455 Non-Rapid 455 Adrenergic Agonists 455 Opioid agonists 458 Dopamine agonists 458 Rapid Adrenergic agonist + opioid antagonists 458 Ultra-Rapid (Adrenergic agonists) + opioid antagonists under anesthesia 460 Reviews 462 Conclusion 462 Appendix References 463 Pharmacotherapy for Opioid Dependence 465

Background 465 Agonists 467 Agonists (Including Partial) Versus Control 467 Agonists versus Other Agonists 469 Agonists versus Antagonists 472 Agonists versus the Same Agonists 472 Distribution Studies 472 Dose Level Studies 473 Antagonists 498 Antagonists versus Control 498

Contents

8.3.2 8.3.2.1 8.4 8.4.1 8.5 8.6 8.7 8.7.1 8.7.2 8.7.3 8.7.4 8.8 8.8.1 8.8.1.1 8.8.1.2 8.8.1.3 8.8.2 8.8.2.1 8.8.2.2 8.8.2.3 8.8.2.4

9 9.1 9.2 9.2.1 9.2.1.1 9.2.1.2 9.2.1.3 9.2.1.4 9.2.2 9.2.3 9.2.4 9.3 9.3.1 9.3.2 9.4 9.4.1 9.4.2 9.4.3 9.4.4 9.5 9.6

Antagonists versus the Same Antagonists 499 Distribution Studies 499 Adjunctive Treatment with Antidepressants for Depressive Disorders 506 Antidepressants versus Control 506 Meta-Analysis 506 Reviews 512 Conclusion 512 Agonists, Including Partial 512 Antagonists 513 Antidepressants 513 Other Illegal Drugs 513 References 514 Appendix 519 Agonists 519 Agonists (Including Partial) versus Control 519 Agonists versus Other Agonists 519 Agonists versus the Same Agonists 519 Antagonists 526 Antagonists versus Control 526 Antagonists versus the Same Antagonists 528 Meta-Analysis 528 Conclusion 529 Appendix References 530 Pharmacotherapy for Cocaine Dependence 533

Background and Pharmacological Principles 533 Long-term Pharmacotherapy in Cocaine Dependence 535 Antidepressants 535 Tricyclic antidepressants 535 SSRI 536 Other antidepressants 536 Meta-analysis 537 Dopamine Agonists 538 Other Dopamine Agonists 538 Antiepileptics 539 Withdrawal Treatment in Cocaine Dependence 541 Dopamine Agonist 541 Partial Serotonin Agonist 541 Interaction Studies 554 Antidepressants 554 Dopamine Agonists 554 Antiepileptics 554 Partial Opioid Agonist 554 Review Articles 554 Long-term Pharmacotherapy in Methamphetamine Dependence 554

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9.6.1 9.6.1.1 9.7 9.7.1 9.7.2 9.7.3 9.7.4

9.8 9.8.1 9.8.1.1 9.8.1.2 9.8.1.3 9.8.1.4 9.8.1.5 9.8.1.6 9.8.1.7 9.8.1.8 9.8.1.9

10 10.1 10.1.1 10.2 10.3

10.4 10.5 10.5.1 10.5.2 10.5.3 10.5.4 10.5.5 10.5.6 10.6 10.7 10.8

Antidepressants 555 Tricyclic Antidepressants 555 Conclusions 555 Long-term Pharmacological Treatment in Cocaine Dependence 555 Withdrawal Treatment in Cocaine Dependence 558 Interactions 558 Long-term Pharmacological Treatment in Methamphetamine Dependence 558 References 559 Appendix 562 Long-term Pharmacotherapy in Cocaine Dependence 563 Antidepressants 563 Dopamine Agonists 563 Antiepileptics 563 Disulfiram 563 Neuroleptics 570 Serotonin Antagonists 570 Opioid Antagonist 570 Stimulants 570 b-Blockers 570 Appendix References 571 Pregnancy, Neonatal Period, and Substance Abuse 573

Introduction 573 Aim 573 Search Strategy and Methods 574 Incidence and Prevalence of Alcohol and Drug Use in Pregnant Women 574 Treatment Research – Alcohol and Pregnancy 575 Narcotics and Pregnancy 576 Cannabis and Pregnancy 577 Amphetamine, Other Central Stimulants, and Pregnancy 577 Cocaine and Pregnancy 577 Opiates and Pregnancy 578 Benzodiazepines and Pregnancy 578 Other Narcotics and Pregnancy 578 Studies of the Treatment of Drug Abuse in Pregnancy 578 Staff Training 579 Summary 579 References 581

Contents

Appendix

Appendix Appendix Appendix Appendix

1. 2. 3. 4.

Project Group Authors and Scientific Reviewers 583 Quality Checklist 585 Guidelines for Estimating Effect Size 586 Glossary 587

Conclusions by SBU 595 SBU Summary 599 Index 611

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1

Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Mikko Salaspuro

1.1

Introduction

Secondary prevention of alcohol problems covers the methods used for early detection and treatment of people with excessive alcohol consumption. The methods aim at preventing the development of alcohol dependence and alcohol-related diseases and injuries. Problem drinking is detected either in primary care or at a hospital by means of screening methods including questionnaires and laboratory tests. Preventive methods are referred to as brief interventions. Brief intervention is based on knowledge about alcohol being a major social and health problem, which reinforces the need to develop new strategies for primary and secondary prevention. Early detection of risk drinking is of central importance to the intervention. When an alcohol problem is detected, the patient receives information about the harmful effects which alcohol abuse or high alcohol consumption may cause. This is followed by a motivational discussion to reduce alcohol consumption. Brief intervention may also involve written advice and followup visits. Table 1.1 presents the framework of brief intervention (FRAMES) as described by Bien et al. [8].

Table 1.1. Content of brief interventions, FRAMES. Feedback of personal risk or impairment Feedback and information about alcohol is given in relation to the patient’s problems and symptoms. Emphasis on personal responsibility The patient’s decision to reduce the drinking should for change be his/her own. Clear advice to change The decision to reduce or quit drinking should be supported. A menu of alternative change options Alternative strategies to reduce drinking are created. Therapeutic empathy as a counseling The interventions are carried out in a warm, style reflective, empathetic, and understanding manner. Enhancement of client self-efficacy or Self-trust and optimism concerning success is optimism encouraged.


2

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems

1.2

Aim

The aim of this systematic review of the literature is to review all published, randomized controlled trials (RCTs) as a basis for drawing conclusions about the effect of brief (minimal) interventions on alcohol consumption and alcohol-related problems.

1.3

Methods 1.3.1

Selection of Studies, Inclusion and Exclusion Criteria

The randomized controlled studies available in the field were systematically reviewed. Some studies included not only people with hazardous consumption levels but also alcohol-dependent individuals. However, the studies that analyzed alcohol dependence exclusively have been excluded. Also excluded were studies undertaken within the framework of substance abuse services or those where participants were recruited by advertising. Furthermore, this review excluded studies which compared brief intervention with more intensive treatment, and studies where the intervention extended beyond what is usual for a brief intervention. No requirements were established concerning the minimally acceptable followup time or the type of staff that performed the intervention. 1.3.2

Search Strategy

The search of the literature for this chapter was limited to MEDLINE from 1966 through 2000, but has been updated more recently to include some of the most important new studies or reviews on the topic. The following search terms were used in combination (number of identified publications are given in parentheses): ● Heavy drinking and intervention (36); – and advice (11) ● Brief intervention and alcohol (52) ● Counseling and alcohol and controlled study (2) ● Intervention and problem drinking (47); – and controlled drinking (5); – and problem drinker (10); – and alcohol consumption and controlled trial (17); – and alcohol and general practitioner (14) ● Intervention and problem drinkers (62) ● Advice and alcohol consumption (91) ● Early intervention and alcohol (104); – and controlled study (2) ● General practitioner intervention (9) ● Alcohol and intervention and controlled trial (44) ● Alcoholism and intervention and controlled trial (19).

1.3 Methods

Bibliographies from the studies found and from previously published meta-analyses, literature reviews, and dissertations were also reviewed [3, 7, 12, 20, 23, 33, 34, 35, 42, 46, 47]. 1.3.3

Outcome Measures

The most important outcome measures applied in the studies were changes in (a) alcohol consumption and (b) alcohol-related problems. Other outcome measures were: changes in laboratory values (GGT, AST, blood alcohol level, MCV), number of sick days, hospital in-patient days, physical or mental illness. 1.3.4

Rating Scientific Quality

The following were considered in rating the quality of the selected articles: randomization, blinding, patient recruitment and selection, criteria for diagnosis and selection, type of control treatment, dropout analysis and documentation on outcome estimates, outcome measures, multicenter studies, delivery of treatment, reporting of the total treatment situation, and statistical methods. 1.3.5

Analyzing the Results

The percentage of individuals in the intervention and control groups who reduced their alcohol consumption to a moderate or more risk-free level was calculated in all studies where this was possible. This information was used to estimate the relative risk reduction (RRR), the absolute risk reduction (ARR), and the number needed to treat (NNT), i.e., the number of heavy drinkers who would need brief intervention to enable each one to reduce his/her alcohol consumption to a more riskfree level [38]. Furthermore, the 95% confidence interval for each NNT was calculated [38].

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1.4

Results 1.4.1

Literature Search

The search of the database and bibliographies in previously published meta-analyses, reviews, and dissertations identified 478 articles. Of these, 27 studies fulfilled the inclusion criteria established by the group. The studies which were excluded usually focused on comparisons between different forms of therapy for alcohol dependence (as discussed above). The absence of a control group or lack of randomization were other reasons for excluding a study. 1.4.2

Previous Reviews and Meta-Analysis

Six systematic and several less comprehensive literature reviews addressed studies of brief interventions [7, 8, 12, 20, 21, 23, 29, 30, 33–35, 42, 46, 47]. The second edition of Hester and Miller’s book on the treatment of alcoholism [20] is based on a systematic evaluation of the literature. Only randomized and case-control studies were included. The review covered 211 studies of which 149 (69%) reported a significant outcome. Twenty-three studies from 1977 to 1992 which addressed brief interventions are included in the review. The analysis by the authors found stronger support for a good outcome from brief intervention than from any other form of treatment. However, Hester and Miller also included studies that compared brief intervention with more intensive forms of treatment, studies that had been performed outside of the standard health care organization, and studies where advertising had been used to recruit problem drinkers. Furthermore, some studies included in the present review were missing in Hester and Miller’s book. Kahan et al. used almost the same inclusion criteria as those used in this review. Eleven studies fulfilled these criteria, but the search strategy failed to identify all randomized studies [23]. The authors concluded that the studies supported the effectiveness of brief intervention. However, they stated that further studies were needed to investigate the effects of brief intervention on morbidity and mortality. Furthermore, uncertainty remained concerning the most suitable patients for intervention, the optimum intensity of intervention, and the most effective components of the brief intervention. Further studies were also found to be necessary to develop strategies to effectively motivate health care staff to use the method. In 1997, Wilk et al. published a meta-analysis of randomized controlled studies of brief intervention in heavy drinkers [47]. Their analysis included 12 randomized studies that fulfilled the inclusion criteria. The quality of the articles was comparable to equivalent studies in other research areas. The authors concluded that heavy drinkers who were subjected to minimal intervention were twice as likely to reduce their alcohol consumption to a more moderate level 6 to 12 months after the intervention compared to the control group which was not exposed to an intervention.

1.4 Results

The outcome was independent of patient gender, intervention intensity, and type of organization. The authors concluded that brief intervention is an inexpensive and effective preventive method for treating heavy drinkers of alcohol who are identified through the health services. A review by Ashenden included studies investigating the effect from different intervention methods on lifestyle changes [7]. The review also included studies which, in addition to alcohol consumption, also addressed patients’ smoking, diet, and exercise habits. In this review, the effect on alcohol consumption was analyzed in only six studies, of which one was nonrandomized. The authors concluded that further studies are needed before any conclusions can be drawn concerning the most effective interventions and the magnitude of the effect. Poikolainen performed a meta-analysis of primary care studies in which he compared brief intervention (5–20 min) to a more extensive intervention (repeated followup visits) [33]. Seven studies were included in the analysis. The outcome measure was a quantitative change in alcohol intake. The brief intervention showed no confirmed effects in either men or women. The more intensive intervention led to a significant reduction in alcohol consumption in women but not in men. Because of the differences in design between the different studies it was not possible to claim that the demonstrated difference in alcohol consumption would apply more generally. The author(s) concluded that further studies are needed to investigate why some interventions yield better results than others. Moyer et al. included two types of studies in their meta-analytic review [27]: studies comparing brief interventions with control conditions in nontreatment-seeking samples (n=34) and those comparing brief interventions with extended treatment in treatment-seeking samples. In studies of the first type, small to medium aggregate effect sizes favoring brief interventions emerged across different followup points. In contrast to this SBU review, the meta-analysis by Moyer et al. also included one study on alcoholics with gastrointestinal disease and five studies (one thesis) that had not been detected in the present literature search or accepted in the final review. Furthermore, Moyer’s review included, as separate entities, nine studies from the collaborative WHO project, which the present review includes as a single entity [45]. On the other hand, Moyer’s review failed to identify nine RCTs on brief intervention that have been included in this report. Nevertheless, the conclusions of these two reviews are largely the same. 1.4.3

Randomized and Controlled Studies

Table 1.2 (see page 6–15) shows characteristic features of the selected 27 randomized controlled studies addressing secondary prevention (brief) in heavy alcohol consumption and alcohol problems, including the number of patients, inclusion and exclusion criteria, type of intervention, followup time, quality rating, main outcome measures, and positive or negative effect. In these 27 studies, 9965 patients (approximately 8000 men and 2000 women) were randomized to intervention or brief intervention groups, brief information groups, investigation groups, or

5

6

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.2. Randomized and controlled studies addressing secondary prevention of alcohol problems. Article, year, care setting

Population, gender, mean age

Inclusion criteria

Exclusion criteria

Anderson and Scott [3] 1992 Primary care

N=154 men 7 community health centers, 44 years

>350 g of alcohol/w

>1050 g of alcohol/w, previous counseling

Antti-Poika et al. [4] 1988 Hospital

N=120 men Trauma patients in the surgical unit, 38 years

MAST ≥7

Severe head injuries

Chick et al. [8] 1985 Hospital

N=156 men Different medical units, 18–65 years

>50 dr/w, alcohol problems

Homeless, demented, severe illness, previous referral to psychiatrist

Córdoba et al. [9] 1998 Primary care

N=229 men 33 community health centers, 37 years

>36 dr (8 g)/w or >10 dr/day during 1 month

Previous advice to reduce, chronic illness

Cushman et al. [10] 1998 Primary care

N=641 636 men, 5 women, 58 years

≥3 dr/day during 6 months, diastolic RR 80–99

Alcohol dependence, drug addiction, severe illness

Elvy et al. [12] 1988 Hospital

N=263 168 men, 32 women Surgical units, 29 years

CAST questionnaire ≥3

Alcoholics, home outside the district

Fleming et al. [13] 1997 64 family practitioners in 17 community health centers Primary care

N=774 482 men 292 women 59.4% = 18–40 years 41.6% = 41–65 years

Men >168 g, Women >132 g/w

65 years, previous problems with alcohol, >50 dr/w

Legend see page 14.

1.4 Results

7

Intervention

Followup period and %

Quality score

Outcome measure

Effect +/–

Control vs brief counseling (10 min) + laboratory tests + book

12 months (65%)

31/33

Alcohol consumption: ↓ IV 45%, C 27%, difference: –65 g/w, p96 g/w, or >3 dr x >2/3 month + >2 CAGE positive answers

Alcoholics, previous counseling, suicidal thoughts, under 65 years of age

Gentiello et al. [16] 1999 Hospital

N=762 579 men 183 women trauma patients, 35–37 years

Elevated blood alcohol, SMAST >1–3, elevated GGT

20 dr/w, or alcohol problems

Alcoholism, severe mental illness, liver disease

Israel et al. [21] 1996 42 general practitioners Primary care

N=105

One positive response in a trauma questionnaire

Alcoholism, GGT >200, mental illness, AA, drug addiction

Kristenson et al. [23] 1983 Department of preventive medicine Hospital

N=473 men, 48–50 years

GGT >1.40 mkat/l

Hypertension, hyperlipidemia, diabetes

Lang et al. [24] 1995 14 companybased physicians Primary care

N=129 95% men, 43 years

RR >140/90 and GGT 1.5 x upper limit for normal level

Severe illness, non-alcohol cause of GGT

Legend see page 14.

age not reported

1.4 Results

Intervention


Quality score

Control (book with general health education) vs 2 interventions (10–15 min) + book

12 months (92.4%), financial compensation to physician and patient

32/33

Control (assistance on demand) vs intervention (30 min) + letter 1 month later, information about AA

6 months (73–76%) 12 months (53–54%)

Control (extensive interview regarding alcohol consumption and problems) vs brief counseling vs interactive DRAMS intervention

9

Outcome measure

Effect +/–

Alcohol consumption:

+

29/30

Alcohol consumption (12 months): IV –21.6 dr, C –2.3 dr, reduction of new injuries 47%, in-hospital stay 48%

+

6 months (88%)

25/33

Alcohol consumption IV –20%; BC –17%; C –16%

–

Brief counseling vs cognitive intervention with laboratory tests (45 min + 6 x 20 min) performed by a nurse

12 months (70%)

28/33

Alcohol consumption: IV –70%, –319 g/w C –46%, –191 g/w psychosocial problems ↓ –85%, GGT ↓ –32%

+

Control vs brief counseling + repeated followup visits with laboratory tests

48 months (88%)

23/33

Sick leave: IV +22%, C + 110%, p 20 dr/w

Diastolic blood pressure >105, diabetes, previous advice

Nilssen [27] 1991 Primary care

N=338 290 men, 48 women, 41–42 years

GGT >50 men, >45 women, alcohol for 2–3 days/w, one bottle of wine 1–2 times/month

Alcoholism, liver disease, mental illness, GGT >200

Ochene et al. [28] 1999 Primary care


Men >12 dr/w or >5 dr/d/month Women >9 dr/w or >4 dr/d/month

Alcoholism, pregnancy, mental illness, no telephone, drug addiction

Persson and Magnusson [29] 1989 Hospital

N=78 61 men, 17 women age ?

A >200 g/w men, >150 g/w women, GGT >0.6 mkat/l

Alcoholism, abuse of prescription drugs or narcotics

Richmond et al. [33] 1995 119 general practitioners Primary care


Alcohol >35 dr/w men, >21 dr/w women

Alcoholism, pregnancy, mental illness, previous treatment or advice

Legend see page 14.

1.4 Results

11

Intervention


Quality score

Outcome measure

Effect +/–

No real C, advice by personal doctor (5 min) vs brief intervention by doctor vs brief intervention by nurse

3, 6, 12 months (99%, 93%, 90%)

26/30

Alcohol advice –40% men, –30% women, IV/physician –55% men, –56% women IV/nurse –46% men, –26% women, ns

–

Control vs brief counseling (10–15 min) + repeated followup visits

8w (87%)

28/30

Alcohol consumption: IV –50%, C 0%

+

Control vs brief counseling vs intervention + book + repeated followup visits

12 months (95%)

27/30

GGT: IV –16%, BC –22%, C +9% Alcohol consumption: double in C vs both IV groups

+

Control (book and health education) vs specific education of physician (2.5 hours) + IV (5–10 min) + followup visit

6 months (91%)

32/33

Alcohol consumption: IV –5.8 dr/w C –3.4 dr/w

+

Control vs brief counseling + >5 repeated followup visits with laboratory tests

24 months (68%)

24/30

Sick leave: IV –44%, C +80%

+

Control vs investigation (5 min) vs intervention (10–15 min) + 4 followup visits

6 and 12 months (69%)

32/33

Alcohol consumption: IV –25%, C –21%

–

(Table continues on next page)

12

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.2. (cont.) Article, year, care setting


Inclusion criteria

Exclusion criteria

Romelsjö et al. [34] 1989 14 general practitioners in 5 community health centers Primary care

N=83 70 men, 13 women, 44–48 years

A >30 g/d women, >40 g/d men, hangover, loss of control, CAGE ≥3, elevated GGT

Alcoholism, drug addiction, mental or severe illness, alcohol not cause of GGT

Scott and Anderson [36] 1990 8 community health centers Primary care

N=72 women 44–47 years

≥21 dr (210 g)/w

>70 dr/w, previous advice

Senft and Polen [37] 1997 3 community health centers Primary care

N=516 359 men, 197 women, 42–43 years

AUDIT 8–21

60

Alcohol not the cause of elevated GGT

Tomson et al. [41] 1998 Primary care

N=222, 22–54 years

GGT >0.89 mkat/l, CAGE 2 +, men >280 g/w, women >210 g/w

Non-alcohol cause of elevated GGT, alcoholism

Legend see page 14.

1.4 Results

13

Intervention


Quality score

Outcome measure

Effect +/–

Brief counseling vs intervention with laboratory tests and repeated followup visits

12 months (87%)

23/33

GGT: IV –17%, C –6%, Alcohol: IV –19%, C –0.4%, Alcohol problems: IV –10%, C –9%

–

Control vs brief counseling (10 min)

12 months (69%)

31/33

Alcohol consumption: IV –27%, C –26%

–

Brief counseling (30 s) vs intervention (15 min) + written advice

6 and 12 months (84%, 80%)

31/33

Reduction of alcohol consumption: IV 19% >C, during 6 months p=0.04, 12% during 12 months p=0.13

+


12 months (52%)

18/30

IV and C no change in MCV

–

Brief counseling vs intervention with repeated followup visits with laboratory tests vs separate reference group (RE)

12 and 24 months (80%, 75%)

28/331 or 26/332

GGT: IV and C Significant reduction RE: significant increase

–1/+2

Control (discussion about GGT with a physician) vs 3 interventions by a nurse

24 months (C 37%, IV 30%)

19/30

IV: Lowering of GGT, C: Increase of GGT

+


14

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.2. (cont.) Article, year, care setting


Inclusion criteria

Exclusion criteria

Wallace et al. [42] 1988 47 community health centers Primary care

N=909 649 men, 272 women, 41–45 years

≥35 dr/w men, ≥20 dr/w women + CAGE ≥2 positive

Alcohol consumption

Severe physical illness, GGT >150

WHO study [45] 1996 Multicenter and multinational Primary care

N=1559 1260 men, 299 women, 36 years

answers

Alcohol consumption >50 g/day men, >32 g/day women

Alcoholism, liver disease

IV = brief intervention group, C = control group, dr = drinks, w = week, ↓ = down, ↑ = up, BC = brief counseling group, RE = reference group. 1 ) comparison between brief counseling and intervention. 2 ) comparison between intervention and the reference group.

1.4 Results

Intervention


Quality score

Outcome measure

Effect +/–

Control vs brief counseling with a book and diary + 1–4 followup visits

12 months (85%)

32/33

Alcohol consumption: IV –45%, C –27%, decreased share of patients with large consumption and lowering of GGT

+

Control vs brief counseling (5 min) vs intervention (15 min) + instruction book

9 months (75%)

32/33

Alcohol consumption in men: IV –21%, BC –27%, C –7%, in women significant decrease in IV, BC, and C

+

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control groups. The samples in most of the studies were representative of the general population, but some studies also included patients from health care centers, hospital units, or outpatient clinics. The number of participants in the different studies varies from 47 to 1559. Fifteen studies included individuals who during the past week had consumed more than 132–500 g alcohol. One study included patients who had consumed three drinks per day during the past 6 months and had a diastolic blood pressure from 80 to 99 mm Hg. Another study included patients with RR >140/90 and a GGT level 1.5 times higher than the normal level. Other inclusion criteria were an elevated GGT or MCV level, positive AUDIT (points 8–21), Cage (≥2 or ≥3), MAST (positive answers ≥2 or ≥7), SMAST (positive answers 1–3), or CAST (positive answers ≥3) questionnaire. One study included patients based only on a positive response in a trauma questionnaire. Most studies excluded alcohol-dependent individuals. Other exclusion criteria were, for instance, previous treatment of alcohol problems, previous advice to reduce alcohol consumption, previous referral to psychiatric treatment, liver disease, severe mental illness, dementia, severe brain damage, homelessness, residence outside of the district, abuse of prescription drugs or narcotics, and abnormal laboratory results not caused by alcohol or pregnancy. The brief intervention varied from short information (5 min) or counseling (10–15 min) up to 60 min of intervention. In one study, the intervention was given in the form of cognitive therapy which was repeated every second month for 1 year (45 min followed by six 20 min sessions). In another study, cognitive behavioral therapy was used, given as 6 sessions during the first 3 months and at least 3 sessions during the next 3 months. The aim of this therapy was to cut alcohol intake in half – or fewer than two drinks per day. Furthermore, the intervention could also include laboratory tests, written instructions, and repeated followup visits (1–6 times). Mainly, the intervention consisted of a motivational discussion about the risks of heavy consumption with advice to reduce alcohol consumption to a level associated with a low risk and few problems. The followup time was usually 12 months; in one study it was 8 weeks, in three studies 6 months, in five studies 24 months, and in one study it was 48 months. Furthermore, two new long-term follow-up studies were added more recently to this review. They report results from either 10 year or 10–16 year follow-up. The quality of the studies was generally moderate or good. Scientific quality in the studies was rated on a scale where the maximum number of points was 30 or 33. The quality rating varied from 18 to 33. 1.4.4

Studies with Positive Outcome (Measures) Presented in Order of Quality (see Table 1.3)

A somewhat more extensive intervention than the usual brief intervention was used in an extensive multicenter study in ambulatory care services for veterans in the United States. The material consisted of 636 men and 5 women with slightly elevated diastolic blood pressure who had been having three or more drinks per day

1.4 Results

for the past 6 months [11]. The intervention was a brief form of cognitive behavioral therapy and was given on six occasions during the 3 subsequent months. The aim was to cut alcohol intake in half or limit alcohol consumption to a maximum of two drinks per day. The strength of this study was that the control group did not receive any advice to reduce their alcohol consumption (Tables 1.2 and 1.4). The followup time varied from 3 to 24 months. During followup, alcohol consumption decreased significantly more in the intervention group. During the first 6 months, alcohol consumption decreased from 432 g/week to 230 g/week in the intervention group and from 445 g/week to 377 g/week in the control group. The reduced level of consumption remained the same after 24 months. In the intervention group, alcohol intake decreased more than 50% during the first 6 months in nearly 50% of the participants. The corresponding number in the control group was 23%. The reduction of the GGT level was significantly greater in the intervention group than in the control group. The effect of the reduced alcohol intake on blood pressure was insignificant. A study from the United States (Wisconsin) investigated the prevalence of problem drinking among 17695 patients in primary care [14]. From this total, 2450 patients were found to have a high alcohol consumption. Of these, 482 men and 292 women were randomized to the control or brief intervention group (Tables 1.2 and 1.4). The patients in the control group were given a general health examination, and their alcohol habits were also discussed. The intervention included two brief counseling sessions (15 min) and an instruction book containing advice, education, and information about a contract to reduce alcohol consumption. Followup was 12 months, and dropout was 7%. Compared to the control group, a significant reduction was found among both men and women in the intervention group as regards the weekly volume of alcohol intake, the number of drinking periods, intoxication episodes, and sick days. The authors concluded that intervention by a family practitioner reduces both alcohol consumption and the use of health services among individuals with excessive alcohol consumption. An economic analysis based on this study showed that the cost savings were approximately 6 times greater (a consequence of less emergency care and inpatient care, and lower rates of crime and traffic injuries) than the costs for the brief intervention [16]. A study conducted at 47 health care centers in Great Britain used a questionnaire to identify patients with a high alcohol consumption [45]. In total, 649 men and 272 women were randomly distributed to a control and an intervention group (Tables 1.2 and 1.4). The patients in the control group received no information about the risks of their alcohol intake. The brief intervention consisted of brief standardized counseling about alcohol-related risk and risk-free drinking and an instruction book. The men were advised not to drink more than 18 drinks (one drink equals one bottle of beer, one glass of wine, or 4 cl of distilled spirits), and the women no more than eight drinks per week. Furthermore, the patients were given a drinking diary and were scheduled for a followup visit (one to four times). The followup time was 12 months, and 85% of the patients participated in the followup. The intervention group showed a significant reduction in alcohol con-

17

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sumption. The authors concluded that if the brief intervention became a routine with general practitioners in England, alcohol consumption would be reduced to a moderate level in 250 000 men and 67 500 women each year. A study from the United States (Massachusetts) randomized four physician offices, staffed by 46 physicians, to special intervention or standard treatment [31]. Two hundred fifty-six patients whose consumption exceeded the threshold value were given standard treatment (control) and 274 patients were given specific intervention (Tables 1.2 and 1.4). The control group, however, received an informational brochure about healthy living. When needed, the physicians also intervened against the patients’ possible alcohol problems. The physicians who belonged to the intervention group participated in a 2-hour patient- and alcohol-oriented educational program. The program included two group sessions with supervision and roleplay. The intervention (5 to 10 min) aimed at focusing on the number of drinks per week, intoxicating drinking, and on followup visits. The followup time was 6 months and 91% of the patients were followed up. A significant reduction in the number of drinks per week could be noted in the intervention group compared to the control group. An elegant study from the United States (Seattle) investigated 2524 trauma patients [17]. Of these, 1153 (46%) met the inclusion criteria for problem drinking. Out of this group, 366 were randomized to an intervention group and 396 to a control group (Tables 1.2 and 1.4). The followup time was 6 and 12 months, and the percentage followed up was 74% and 53%, respectively. After 12 months, the intervention group showed a significant reduction in alcohol consumption. The reduction was most obvious in patients with mild or moderate alcohol problems. Alcohol consumption in the intervention group declined along with a simultaneous, significant reduction in injuries requiring treatment in an emergency department and a 50% reduction in injuries normally requiring hospitalization. The authors concluded that there should be a routine attempt to detect and intervene against alcohol problems in emergency departments. WHO performed a large study in Australia, Kenya, Mexico, Norway, England, and Russia [48]. Hospital units, outpatient clinics, community health centers, and an institution for health examinations were called “functional units” (Tables 1.2 and 1.4). In total, 1260 men and 299 women whose alcohol consumption exceeded the threshold value were randomized to three groups: a control group, a brief counseling (5 min) group which received information about reasonable limits for drinking, and an intervention group (15 min) which received an illustrated instruction book addressing problem drinking and advantages of moderate drinking or abstinence. The mean followup time was 9 months, and the followup rate was 75%. After 9 months, the men in both the intervention groups reduced both their alcohol consumption and drinking intensity significantly more than the men in the control group. Among the women, a significant reduction in alcohol consumption could be noted in all three groups. A brief intervention was as effective as a longer one. The authors concluded that brief interventions are effective methods in certain health care organizations and cultures and, if sufficiently used in primary care, could improve secondary prevention of alcohol-related problems.

1.4 Results

A 9-month and 10-year followup was carried out in the cohort of 554 (nondependent) hazardous and harmful drinkers recruited into the Australian arm of the Phase II World Health Organization collaborative project (described above) [49]. The effectiveness of these forms of intervention, ranging from 5 to 60 min duration, was compared with a no-treatment control condition. The results provided further evidence for the short-term effectiveness of alcohol-related brief interventions. In comparison to controls, subjects offered intervention reported significantly lower consumption and less unsafe drinking at 9-month followup. However, analysis at 10 years failed to find any differences in outcomes between intervention and control groups in median consumption, mean reduction in consumption from baseline to followup, mortality, and ICD-10 diagnoses of alcohol dependence or harmful alcohol use. A new study by Fleming et al. indicates that the brief intervention is effective even in elderly problem drinkers [15]. Among 6073 patients above 65 years of age, 656 individuals with a high alcohol consumption were identified. Of these, 105 men and 53 women were randomized to the control or brief intervention group (Tables 1.2 and 1.4). The control patients were given a book with general health information. The intervention consisted of two brief counseling sessions (15 min) and an instruction book which contained advice, education, a contract on reducing alcohol consumption, and a drinking diary. The followup time was 12 months and the followup rate was 92%. Both physicians and patients received financial compensation for their participation in the study. The intervention group reduced weekly alcohol consumption by 34% and intoxicating drinking by 74% compared to the control group. The number of individuals who drank above the threshold value declined significantly in the intervention group compared to the control group. All differences were significant. A study which included only men was performed in Great Britain (Oxford) [4]. In this study, 154 men were randomized to two groups: a control group and a group which received brief counseling and an instruction book and on whom laboratory tests were taken (Tables 1.2 and 1.4). The followup time was 12 months and the followup rate was 65%. The intervention group showed a significant reduction in alcohol consumption compared to the control group. However, the differences in changes of laboratory tests were not significant. A study in three health centers in Oregon Kaiser Permanente randomized 516 individuals to a group which received brief information (30 s) from general practitioners followed by a 15 min motivating session with a health counselor and to a control group which received only the brief information (Tables 1.2 and 1.4) [40]. After 6 and 12 months of followup, the intervention group showed a significant reduction in the number of standard drinks during the past 3 months and in the number of drinking days per week compared to the control group. The authors concluded that within a primary care setting, a brief, occasional, and motivating intervention could achieve a significant reduction in alcohol consumption. However, it was proposed that new studies are needed to investigate whether and how the effects of the brief intervention can be enhanced and maintained.

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A British study investigated the effects of brief intervention in patients with concurrent hypertension (Tables 1.2 and 1.4) [27]. The study was performed in primary care in a specialized blood pressure clinic. Forty-seven men with hypertension (diastolic blood pressure 90–105) who drank above the threshold value (>20 drinks/week) were randomized to 2 groups: a control group and a group which was given brief counseling (10 to 15 min), respectively, with repeated followup visits. The followup period was 8 weeks and the followup rate was 87%. Alcohol consumption was halved in the brief intervention group, but was not affected in the control group. The reduction in alcohol intake showed a significant association with a reduction in liver enzyme values. Diastolic blood pressure also decreased in the intervention group. The authors concluded that brief intervention is an active treatment form for patients with hypertension and excessive alcohol consumption. In a study from Norway (Tromsö), a general health examination was performed in which 21 000 men and women answered 5 questions concerning alcohol consumption [30]. Their GGT levels were also analyzed. From these, 290 middle-aged men and 48 women with an elevated GGT level and excessive alcohol consumption were selected and randomized to a control group and two intervention groups (Tables 1.2 and 1.4). The strength of the study lies in the fact that the control group was not given any information about screening results or GGT level. In the brief intervention (10–15 min), the following were provided: information about possible causes behind the elevated GGT level, advice to check on possible causes of the abnormal laboratory value, and an instruction book which described the effect of alcohol consumption on GGT levels. The “lengthy” intervention was aimed at decreasing alcohol consumption, and therefore information was given about different methods of achieving this. In addition, the subjects were given a diary to monitor alcohol consumption, and GGT levels were measured on repeated followup visits. The followup period was 12 months, and dropout was only 5%. The lowering of the GGT level was significant in both intervention groups in comparison with the control group. The level decreased in the intervention group by 16% and in the brief counseling group by 22%, but increased by 9% in the control group. A significant reduction in self-reported alcohol consumption was observed in both intervention groups. After 12 months, the subjects in the control group consumed twice as much alcohol as those in the two intervention groups. No significant differences in alcohol consumption or GGT level were found between the 2 intervention groups. The authors conclude that simple interventions may achieve important changes in drinking habits during the early phase of hazardous alcohol consumption. A study from Scotland (Edinburgh), which involved both inpatients who were heavy drinkers and inpatients with alcohol dependence, randomized 156 men to a control group and an intervention group (Tables 1.2 and 1.4) [9]. The control group received standard treatment and no information about the purpose of the screening instrument. In the 60-min intervention, a nurse informed the patient about the risks of high alcohol intake and gave the patient an instruction book. The aim was to reduce alcohol intake or to achieve complete abstinence. The followup period was 12 months and the followup rate was 83%. Alcohol consumption decreased signif-

1.4 Results

icantly in both groups. Furthermore, the intervention group showed a significant reduction in alcohol-related problems and GGT levels compared to the control group. The authors concluded that a systematic survey of alcohol consumption and problems in combination with an intervention should become routine in all patient investigations. A multicenter study by Israel et al. (involving 42 primary care physicians in Canada) questioned 15 686 patients about trauma experienced during the past 5 years [22]. The patients who answered positively to two or more of the trauma questions were given a questionnaire which surveyed their alcohol consumption (Tables 1.2 and 1.4). One hundred and five patients (18% women) who drank above a threshold value were randomized either to brief counseling or to an intervention group. The patients who were included in the counseling group were recommended to reduce their alcohol consumption and were given written advice aimed at achieving either abstinence or an acceptable level of consumption. The intervention was carried out by a nurse, who gave a standardized counseling lasting for 30 min. The goal was to achieve either abstinence or risk-free drinking. The participants were recommended to avoid alcohol in the evening and to keep a diary about their use of alcohol. During the 20-min followup visits, which were repeated every second month for one year, information was given about possible changes in the GGT level, and the strategy for reaching the treatment goal was repeated. The followup period was 12 months and the dropout rate was 30%. The patients in the intervention group reduced their alcohol consumption by 70%. Psychosocial problems decreased by 85%, the GGT level by 34%, and medical visits by 34%. All differences in relation to the control group were significant. The patients in the group given brief counseling reduced their alcohol consumption by 46%, while the changes of other outcome measures were not significant. The authors concluded that the cognitive intervention with repeated followup visits was more effective than counseling alone in reducing alcohol-related objective problems in trauma patients. In a Spanish multicenter study, 229 male primary care patients whose drinking exceeded the threshold value were randomized to a group which was given brief counseling (5 min) and to a group which also received the counseling plus an instruction book and an average of 1.5 followup visits (Tables 1.2 and 1.4) [10]. The followup period was 12 months, but the followup rate was only 45%. In the intervention group, 67% of the high consumers achieved a moderate consumption level. In the control group, the corresponding figure was 44%. The difference is statistically significant. Elvy et al. carried out an intervention study in hospitals in New Zealand aimed at examining the effects of a specific type of consultation on the patient’s alcohol problems (Tables 1.2 and 1.4) [13]. The CAST questionnaire (Canterbury Alcoholism Screening Test) was used to screen for alcohol problems among patients in two surgical units. In total, 200 patients (168 men and 32 women) who fulfilled the inclusion criteria were randomized to a control and an intervention group, respectively. The intervention was performed by a psychologist and was aimed at encouraging the patient to accept a referral to an alcohol counselor. The patients who accepted the referral met with the consulting physician within 24 h. Followup was done after

21

22


12 and 18 months among 74% and 61%, respectively, of the randomized patients. After 12 months a significant improvement could be demonstrated in the consultation group compared to the control group with respect to the number of self-reported alcohol problems, personal satisfaction, and working capacity. However, the differences between intervention and control groups decreased in the 18-month followup. The authors assumed that the followup visit after 12 months might have functioned as a brief intervention in the control group. The authors recommend that this type of consultation become standard hospital routine. A study by Antti-Poika et al. was performed in Finland (Helsinki University Hospital) [5]. One hundred and twenty male accident patients who answered positively to 7 or more MAST questions were randomized to a control group and a brief intervention group, respectively (Tables 1.2 and 1.4). This study may have included even alcohol-dependent individuals. The patients in the control group were given routine surgical or orthopedic treatment. The intervention group received a brief motivational counseling aimed at making the patient abstinent during a certain time period or to reduce his/her alcohol consumption to a more risk-free level. Furthermore, these patients were given an instruction book, and the intervention was repeated 1 to 3 times at followup visits. The followup time was 6 months and dropout was 24%. The intervention group reduced its alcohol consumption significantly compared to the control group which increased its alcohol intake by 73g per week. A significant reduction in alcohol consumption associated with a normalization of the GGT level could also be observed in the intervention group compared to the patients in the control group. According to the authors, this type of intervention ought to become standard routine in treating patients with alcohol-related accidents. An equivalent study involving hospital patients was performed by Persson and Magnuson [32]. This study randomized 61 men and 17 women to a control group and an intervention group (Tables 1.2 and 1.4). The intervention consisted of brief counseling, plus 5 or more followup visits with laboratory tests. Followup was 24 months, and the followup rate was 68%. During 2 years after the intervention, absenteeism due to illness decreased in the intervention group by 44% compared to 21% in the control group, a significant difference. The first pseudo-randomized brief intervention study was performed by Kristenson et al. [25]. This study was included as part of a general health examination which was performed by the department of preventive medicine in Malmö, Sweden (Tables 1.2 and 1.4). Of the 11 643 middle-aged men examined, 473 with an elevated GGT level were assigned (based on birth date) to two groups; either a control group or a group which was given brief counseling with repeated followup visits and laboratory tests every 3 months initially and less frequently after normalization of the GGT level. The followup period was 48 months and dropout 24%. Sick leave increased by 22% in the intervention group and 110% in the control group, which was a significant difference. Furthermore, the intervention group had 60% fewer hospital inpatient days, which was significantly less than in the control group. The authors concluded that intervention programs are effective for preventing the consequences of excessive alcohol consumption. Long-term followup of mortality for 10 to 16 years (median, 13 years) showed that 124 of 978 men had died (12.7%) [24].

1.4 Results

In 59 men (48%), death was alcohol-related. In the intervention group 10.4% and in the control group 13.9% men had died, and the difference was statistically significant. However, the difference between the groups in total mortality was not significant. The authors conclude that long-term intervention in urban males with alcohol-induced GGT increases may be beneficial in terms of survival. A study by Thomson et al., which was part of a general health survey of 2338 individuals in Stockholm, randomized 222 patients with elevated GGT levels to an intervention group and a control group (Tables 1.2 and 1.4) [44]. The patients in the intervention group met with a nurse 3 times during one year. The discussion focused on life style and alcohol consumption. A followup of the GGT levels was used to motivate the patients to reduce their drinking. The control group met with a general practitioner, who informed them that the elevated GGT level was probably caused by excessive alcohol consumption, but no advice was given on how they should reduce this. After 24 months the GGT level decreased significantly in the intervention group, while it increased in the control group. Dropout was as high as 70% in the intervention group and 67% in the control group, which makes interpretation of the results difficult. 1.4.5

Studies without Significant Effects, Presented in Order of Quality (Table 1.5)

A multicenter study conducted in Australia (Sydney) was unable to demonstrate any effect from brief intervention [36]. The patients who drank above the threshold value were recruited by 119 general practitioners in 40 community health centers (Tables 1.2 and 1.5). Two hundred and sixteen men and 152 women were randomized to four groups: (1) control group, (2) investigation only, (3) brief counseling (5 min), and (4) intervention (10–15 min) with four followup visits. The followup period was 6 and 12 months, and the followup rate was 69%. Alcohol consumption decreased by approximately one fourth in all groups. No differences in the change of GGT levels or MAST points were observed. The authors concluded that brief interventions were not shown to be effective in reducing alcohol consumption or alcohol-related problems. They also discussed weaknesses of the study and recommended new guidelines for further studies with brief intervention in primary health care. A study from Great Britain (Oxford) randomized 72 women who drank more than the threshold value to a control group and a group which was given brief counseling (10 min) and an instruction book and on whom laboratory tests were taken (Tables 1.2 and 1.5) [39]. Followup was 12 months and the followup rate was 69%. In these women, alcohol consumption decreased by approximately one fourth in both the intervention and the control groups. The authors suggest that general practitioners should routinely ask their patients about alcohol consumption and advise those at higher risk. A possible reason why no effect was found from brief intervention may have been that the control group received indirect intervention from the general practitioners. Perhaps the diagnostic interview already had an impact on the women.

23

24


In a multicenter study from Australia (Sydney), McIntosh et al. compared the outcome of three brief intervention methods on alcohol consumption in patients who went to family practitioners (Tables 1.2 and 1.5) [28]. The study randomized 83 men and 76 women whose drinking exceeded the threshold value into three groups: the first group members received advice (5 min) from their own physicians, the second group received brief intervention (2 x 30 min) by a physician, and the third group received brief intervention (2 x 30 min) by a nurse. Followup took place after 3, 6, and 12 months and included 99%, 93%, and 90% of the subjects respectively. A significant reduction in alcohol consumption (47% in men, 37% in women) was noted for the entire study group, but the differences between intervention and control were not significant. At the beginning of the study, 15% of the men and 22% of the women were problem free. The corresponding figures 12 months after the different interventions were 39% in the men and 53% in the women. The authors conclude that basic advice from a physician can motivate patients to reduce their alcohol consumption and that intervention by a nurse is as effective as the equivalent intervention by a physician. A primary care study performed in France (Paris) differs somewhat from other intervention studies [26]. This study was included because its aim was to reduce the alcohol consumption of patients with hypertension using a special form of brief intervention. In the study, 14 company-based physicians were randomized to an intervention and a control group (Tables 1.2 and 1.5). The physicians in the intervention group were educated in a new way of working with patients with hypertension who were heavy consumers of alcohol. One hundred and twenty-nine patients (95% men) with blood pressure above 140/90 and a GGT level 1.5 times the reference value were included in the study. The specially trained company-based physicians treated 67 patients. The 62 patients in the control group were treated by their own physicians in the usual manner, which could include different measures against excessive and harmful alcohol consumption. The patients in the intervention group were called to the clinic after 1, 3, 6, and 18 months, and their GGT levels were checked each time. The subjects were encouraged to find a level of alcohol consumption which would reduce their GGT levels to normal values. Blood pressure, which was measured in both groups at the outset and after 12 and 24 months, was not the focus of this study. The followup periods were 12 and 24 months and the followup rates were 90% and 78%, respectively. Alcohol consumption decreased by 238 g per week in the intervention group and by 131 g per week in the control group. The difference was not significant, which may have been because of the limited number of patients. However, a significant reduction in systolic blood pressure was found in the intervention group compared to the control group after both 12 and 24 months. No difference between the groups could be noted in the diastolic blood pressure or in the GGT levels. In Finland, Suokas conducted a randomized brief intervention study in a midsized city [43]. This study was part of a general health survey including middle-aged men (Tables 1.2 and 1.5). In 3844 men examined, 247 with an elevated GGT level were randomized to two groups: one group was given brief counseling (10–15 min) by a physician and the other was exposed to a longer intervention with an instruc-

1.4 Results

tion book and repeated followup visits with a nurse. Another 200 persons, with the same alcohol consumption as in the two intervention groups, were included to monitor changes in the GGT levels of individuals who received information that their liver values were normal. However, they did not receive any information about the risks of their excessive alcohol consumption. This reference group was not randomly recruited. The followup periods were 12 and 24 months and the followup rates were 80% and 75%, respectively. A significant reduction was found in the GGT levels in both intervention groups, while the reference group had a significant increase in the GGT level. Alcohol consumption and GGT level did not differ between the two intervention groups. A study by Heather et al. at eight community health centers in Scotland recruited patients whose drinking exceeded the threshold value (Tables 1.2 and 1.5) [19]. The study randomized 78 men and 26 women to three groups: (i) a control group which involved an interview on alcohol consumption and alcohol-related problems and brief advice, (ii) a group which was given an interactive DRAMS program (DRAMS = drinking reasonably and moderately with self-control scheme), and (iii) a group to which a physician gave short advice. DRAMS included a four-page instruction from a physician, a followup form to fill in results from laboratory tests (blood alcohol, GGT, MCV), a diary for noting alcohol intake, and an instruction book for controlled drinking. The followup time was 6 months and dropout was 12%. No differences in alcohol consumption were found between the three groups, but in the material as a whole a significant reduction could be noted in alcohol consumption and the GGT level, while physical condition improved. The authors conclude that their results can be used in planning future brief intervention studies. Romelsjö et al. identified heavy drinkers of alcohol and people with alcohol problems via a general health examination, which was performed in five community health centers in Stockholm (Tables 1.2 and 1.5) [37]. The study randomized 70 men and 13 women who fulfilled the inclusion criteria to two groups: either to brief counseling by their own physician about reducing their alcohol consumption or to a group which in addition received laboratory tests and were scheduled for repeated followup visits. The followup period was 12 months and the followup rate was 87%. Alcohol consumption, GGT levels, and the number of alcohol problems decreased more in the intervention group than in the brief counseling group, but the differences were not significant. A study by Seppä randomized 140 men and 38 women with an elevated MCV level to a control group and to a group which was given brief counseling and repeated followup visits and laboratory tests (Tables 1.2 and 1.5) [41]. The followup period was 12 months and dropout was as high as 48%. No significant differences in MCV levels could be noted between the two groups. More recently, Aalto et al. recruited 296 male early-phase heavy drinkers who had consulted a general practitioner for various reasons [1]. Those in the control group (n=88) were informed of the risks of drinking after screening and were advised at the subsequent feedback session about 2 weeks later to reduce their drinking. Two other groups (n=109 or 99) were offered, in addition, either seven or three brief intervention sessions, respectively. No statistically significant differences were

25

26


found between the study groups, either in self-reported alcohol consumption or in laboratory markers. However, all groups significantly reduced their alcohol consumption in 25–53% of the subjects, and this was associated with a significant decrease in the MCV value. The quality of the study was high and followup was 36 months. The dropout rates were 39% and 30% in the two intervention groups and 24% in the control group.

1.5

Analysis of the Overall Results of the Reviewed Studies

The quality in 25 out of 27 studies was high, good, or moderate, and was acceptable in 2. In the 25 studies, the quality rating varied from 33 of 33 possible to 23 of 33 or from 29 of 30 possible to 24 of 30 (Table 1.2). Seven of the studies had been performed in large patient groups, from 516 to 1559 subjects (total = 5691). It may be noted that the quality of the articles was comparable to that in equivalent studies in other areas of research. A meta-analysis of the studies was not judged to be meaningful, since inclusion criteria, intervention methods, and outcome measures were too heterogeneous. However, relative and absolute risk reductions were calculated in the individual studies when possible. Based on these figures, NNT (Number Needed to Treat) was also calculated. NNT is the number of heavy drinkers or persons with an alcohol problem who should receive brief intervention in order that one individual reduces his/her alcohol consumption to a more risk-free level. This information is given in Table 1.3,where the individual studies are listed in the order of their quality. 1.5.1

Studies with a Positive Outcome

In 18 out of 25 randomized controlled studies – of at least moderate quality – brief intervention had a significant positive effect (Tables 1.2 and 1.4). These 18 studies included 7812 individuals (6198 men and 1614 women) from general health care. Six of the studies which were carried out in primary health care and one study which was carried out in hospitals included a particularly large number of patients and were of high quality. In the seven studies, the intervention varied from brief counseling to a form of cognitive therapy in 6–9 sessions during 1 year [11, 48]. In 2 of these 7 studies, the significant difference in reduction of alcohol consumption could be confirmed by a significant difference in the reduction of the gamma GGT level [11, 45]. Furthermore, 2 of these studies showed a significant reduction in the number of hospital days and 1 study showed a significant reduction in the incidence of new injuries and the need for hospital care [14, 17]. In 12 of the studies mentioned above it was possible to calculate the relative risk reduction (RRR), the absolute risk reduction (ARR), and the number (NNT) of persons needed to receive an intervention in order that one individual reduces his/her alcohol consumption during 6 to 24 months to a more risk-free level (Table 1.3) (see

1.5 Analysis of the Overall Results of the Reviewed Studies

page 28-29). The results from the 6 other primary care-based studies also show positive effects (Table 1.4) (see page 30-33) [10, 25, 27, 30, 40, 44]. In one of these, a significant reduction in sick leave during 48 months in comparison with the control group could be shown [25]. The study by Maheswaran et al. showed a correlation between the reduction in alcohol consumption and a significant reduction in the GGT level and blood pressure [27]. Two more recent studies have addressed the long-term effects of brief interventions. One of these showed a decreased alcohol-related mortality after 10–16 years of the intervention. The long-term (10 years) effects of brief intervention, however, were negative in the other study. Six studies, which showed positive effects on alcohol consumption, were performed in hospital patients (Table 1.4). Further significant findings in these studies were: a reduction in the GGT level and fewer alcohol-related problems in one study, and reduction of psychosocial problems and physician visits in another study. Fewer alcohol problems, greater personal well-being, and better working capacity were shown in one study [13]. A reduction in sick leave and a reduction in new injuries and the need for hospital care could be documented in two studies (Table 1.4) [17, 31]. It can also be noted that in 8 of the 17 studies which showed a reduction in alcohol consumption, other positive effects could also be demonstrated. In most cases, these additional positive effects indicate a significant reduction in the negative effects caused by alcohol.

27

28

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.3. Relative (RRR) and absolute (ARR) risk reduction. Number (NNT) of problem drinkers who would need to have a brief intervention for one person to reduce his/her alcohol consumption to a more risk-free level. Article

Followup period

Type of intervention

Intervention group Number with reduced alcohol consumption/ total number (Intervention %)

Cushman et al. [10] 6 months 12 months 24 months

Extensive intervention

141/320 (44) 141/320 (44) 118/320 (37)

Fleming et al. [13]

12 months

2 brief counseling sessions + book

100/160 (63)

Wallace et al. [42]

12 months

Brief counseling + book + followup

201/448 (45)

Ochene et al. [28]

6 months

Education of the physician followed by intervention

102/274 (37)

WHO study [45]

6 months 6 months

One brief counseling Brief intervention + book

111/496 (22) 104/576 (18)

Fleming et al. [14] (>65 years)

12 months

2 interventions (10–15 min) + book

11/78 (29)

Richmond et al. [33] 12 months

Brief and extensive intervention

34/136 (25)

Anderson et al. [3]

12 months

Brief counseling + book + lab test

14/80 (18)

Scott et al. [36]

12 months

Brief counseling + book + lab tests

9/33 (27)

Chick et al. [8]

12 months

Intervention (60 min) + book

34/69 (49)

Antti-Poika et al. [4] 6 months

Intervention + book + followup visit

22/49 (45)

Heather et al. [18]

Brief or extensive intervention

9/59 (15)

6 months

RRR = Int % – Cont % / Int % ARR = Int % – Cont % NNT = 1 / ARR CI = Confidence interval for ARR.


29

Control group Number with reduced alcohol consumption/ total number (Control %)

Relative risk reduction RRR (%)

Absolute risk reduction ARR ± CI (%)

Number (NNT) of heavy drinkers needed to have brief intervention for one to reach a more risk-free level

Confidence interval (CI)

74/321 (23) 83/321 (26) 67/321 (21)

48 41 43

21±7 18±7 16±7

5 6 6

4–7 4–9 4–11

57/176 (32)

49

31±10

3

2–5

122/459 (27)

40

18±6

6

4–8

66/256 (26)

30

11±8

9

5–33

59/486 (12) 59/486 (12)

45 44

10±5 6±4

10 17

7–20 10–50

0/67 (0)

100

29

3

1–13

13/61 (21)

16

4±13

25

6–

4/74 (5)

72

13±10

8

4–33

10/39 (26)

4

1±

100

–

20/64 (31)

37

18±16

6

3–50

8/40 (20)

56

25±19

4

2–17

3/32 (9)

40

6±14

17

5–

30

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems T 1able 1.4. Characteristics of the studies with a positive outcome presented in order of quality. Article

Characteristics

Intervention/comparison

Cushman et al. [10] Primary care

Large database N=641 High quality 33/33

C (no advice about alcoholism) vs a brief form of cognitive therapy for 6–9 months or several sessions for 1 year

Fleming et al. [13] Primary care


C (general health examination) vs 2 brief counseling sessions + instruction book

Wallace et al. [42] Primary care


C (no info) vs 1 brief counseling + instruction book + drinking diary + 1–4 followup visits

Ochene et al. [28] Primary care


C (general health examination) vs education of the physician (2.5 hours) + IV (5–10 min) + followup visit

Gentiello et al. [16] Hospital


C (routine treatment) vs intervention (30 min) + letter 1 month later

WHO study [45] Primary care


Control vs brief counseling (5 min) vs 1 brief intervention (15 min) + instruction book

Fleming et al. [14] All >65 years Primary care

Adequate database N=158 High quality 32/33

C (general health examination) vs 2 interventions (10 + 15 min) + instruction book

Anderson & Scott [3] Primary care

Adequate database N=154 High quality 31/33

Control vs 1 brief counseling (10 min) + laboratory tests + instruction book

Senft & Polen [37] Primary care


C vs 1 brief advice (30 s) + motivational guidance (15 min) + written information

C = control; IV = intervention.


Outcome measure: Changes in alcohol consumption

Outcome measure: Changes in GGT

Outcome measure: Other changes

Significant difference in reduction of alcohol consumption and hazardous drinking

Significant difference in reduction of GGT level

Non-significant difference in reduction of blood pressure

Significant difference in reduction of alcohol consumption, periods of drinking, and drinking until intoxicated

Not analyzed

Significant reduction in number of days in hospital

Significant difference in reduction of alcohol consumption and number of patients with high consumption

Significant difference in number of individuals with reduction of GGT level

Significant difference in reduction of the alcohol consumption

Not analyzed

Significant difference in reduction of alcohol consumption

Not analyzed

Significant difference in reduction of alcohol consumption and intensity of drinking, difference between brief counseling and IV not significant

Not analyzed


Not analyzed


No significant changes


Not analyzed

Significant reduction in number of new injuries and medical care


31

32

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.4. (cont.) Article

Characteristics


Maheswaran et al. [25] Primary care

Small database N=47 High quality 28/30 Patients with hypertension

Control vs brief counseling + repeated followup visits

Nilssen et al. [27] Primary care

Large database N=338 Good quality 27/30

C (no advice) vs brief IV (10–15 min) + instruction book vs long IV + diary + followup visit

Chick et al. [8] Hospital

Sufficient database N=156 Good quality 27/30

C (standard treatment) vs intervention (60 min) + instruction book

Israel et al. [21] Hospital

Sufficient database N=105 Good quality 28/33

Brief advice vs intervention (30 min) by nurse + 6 followup visits (20 min)

Córdoba et al. [9] Primary care


Brief advice (5 min) vs intervention (15 min) + instruction book + followup visit

Elvy et al. [12] Hospital


C (standard treatment) vs brief IV with intention to make the patient accept a referral to an alcohol counselor

Antti-Poika et al. [4] Hospital

Sufficient database N=120 Moderate quality 24/30

C (standard treatment) vs brief advice + instruction book + 1–3 followup visits

Persson et al. [29] Hospital

Small database N=78 Moderate quality 24/30

C (standard treatment) vs brief advice + >5 followup visits with laboratory tests

Kristenson et al. [23] Primary care

Large database N=473 Moderate quality 23/33


Tomson et al. [41] Primary care

Sufficient database N=222 Acceptable quality 19/39

Control vs 3 interventions by a nurse

C = control; IV = intervention.





Significant reduction (50%) in intervention group, not in control group

Significant reduction (21%) in intervention group only

Significant reduction in AST (18%) and RR in intervention group only

Significant reduction in 2 of the IV groups, no difference between the IV groups

Significant reduction in the IV groups, not significant increase in the control group


Significant difference in reduction of the GGT level

Fewer alcohol-related problems in the intervention group

Significantly greater reduction of alcohol consumption in the intervention group

Significant reduction in the intervention group but not in the brief advice group

Significant reduction of psychosocial problems and medical visits in IV but not in brief advice groups

Significant reduction in alcohol consumption, significant difference between the groups

Not analyzed

Significantly longer time until the first drink in the intervention group

Not analyzed

In the intervention group: fewer alcohol problems, greater personal happiness, and better working capacity

Significantly greater reduction in the intervention group

Significant reduction in the intervention group

Significant improvement in the intervention group in comparison with controls

Reduction in the intervention group

Reduction in the intervention group

Significant reduction in sick leave in the intervention group, increase in the control group

Not analyzed

Significant reduction in both groups, but no difference between groups

Significant reduction of sick leave and fewer days in hospital in comparison with control group

Not analyzed

Reduction in intervention group, increase in control group

33

34

1 Intervention against Hazardous Alcohol Consumption – Secondary Prevention of Alcohol Problems Table 1.5. Characteristics of the studies which did not show any significant effects. Article

Characteristics


Richmond et al. [33]


Control (investigation only) vs brief advice (5 min) vs brief intervention (10–15 min) + 4 followup visits

Scott & Andersson [36]

Moderate database N=72 women High quality 31/33

Control vs brief advice (10 min) + laboratory tests + instruction book

McIntosh et al. [26]


Advice (5 min) by physician vs intervention by physician (2 x 30 min) vs intervention by nurse (2 x 30 min)

Lang et al. [24] Patients with hypertension

Moderate database N=129 Good quality 29/33

Control vs followup of the GGT level with motivation to reduce alcohol consumption

Suokas [40]


Brief counseling (5 min) by physician vs intervention with followup visits (2–3) and laboratory tests

Heather et al. [18]

Moderate database N=104 Moderate quality 25/33

Control (extensive interview) vs brief advice by physician vs DRAMS intervention

Romelsjö et al. [34]

Moderate database N=83 Moderate quality 23/33

Brief counseling by physician vs intervention with laboratory tests and repeated followup visits

Seppä [38]

Large database N=300 Acceptable quality 18/30

Control vs brief advice + repeated followup visits with laboratory tests

↓ = down, ↑ = up.





21–25% reduction in all 3 groups, no differences among groups

Not significant reduction in all groups

MAST points: no differences

Intervention: ↓ 27% Control: ↓ 26%

No significant changes

Significant reduction in dependence scale in both groups

26–56% reduction in all groups, no differences among groups

Not analyzed

14% problem-free in the beginning and 45% after 12 months in all 3 groups

Reduction in both groups, no differences among groups

Reduction in both groups, no significant differences between the groups

Greater reduction in RR in the intervention group

Both groups: no significant changes

Significant reduction in both groups, no difference between the groups

No significant differences in alcohol problems or number of sick days

Significant reduction in all groups, no differences among groups

Significant reduction in all groups, no difference between the groups

Improved physical condition in all groups

Reduction in both groups, no differences among groups

Reduction in both, no significant differences between the groups

No change in the MCV level

35

36


1.5.2

Studies which Showed No Effects

The 8 studies which reported no effects involved a significantly smaller number (n=1472) of individuals (Table 1.5) (see page 34–35). This increases the probability of not detecting actual differences among the compared groups. In 3 of the negative studies there was no real control group, but a brief counseling by a physician was actually compared with more intense forms of intervention [28, 37, 43]. In 4 other studies with a negative outcome (measure), alcohol consumption decreased in all groups, and in 2 groups a significant reduction in the GGT level was noted, while no significant differences could be shown between the different intervention groups [19, 26, 36, 39]. Other effects which were observed in the 4 studies were a significant reduction in the dependence scale in both groups, improved physical condition in all 3 groups, and a greater reduction in the blood pressure in the intervention group (Table 1.5) [19, 26, 39]. The quality of the last, negative study was lower but acceptable. Only the change in MCV level was used as an outcome measure [41].

1.6

Important Aspects of Brief Intervention 1.6.1

Analyses of Special Groups

It would be interesting to compare the effectiveness of brief intervention in different subcategories such as women and hospitalized patients. It would also be of value to study differences between the effects of brief and more intensive interventions. However, it is well known that the risk of false positive and false negative effects increases significantly if subgroups of patients are analyzed retrospectively. The effectiveness of brief intervention in women can best be judged based on the results from the largest and best studies. The study by Cushman et al. included only 5 women [11]. In the study by Fleming et al., the greatest reduction in alcohol consumption, nearly 50%, could be attributed to the women in the intervention group (n=148) [14]. After 12 months, 22% of the women drank more than the threshold value for hazardous alcohol consumption in the intervention group as compared with 49% in the control group. The difference was statistically significant. The study by Wallace et al. included 272 women, and here alcohol consumption decreased significantly and approximately as much in men as in women [45]. In the WHO study, the 299 women significantly reduced their alcohol consumption both in the intervention group and in the control group, but the differences between the groups were not significant [48]. The same results were also achieved in the study by Scott and Anderson which included only women (n=72) [39]. Based on this limited material, it can be assumed that brief intervention has the same effect on women and men.

1.7 Problems with Dropout in Studies

In 8 studies, brief counseling given by a physician was compared to a more intense form of intervention [19, 22, 28, 30, 36, 37, 43, 48]. In 7 of these studies, no difference in effect between the 2 types of intervention was found. In one study it was found that cognitive intervention with repeated followup visits and laboratory tests was significantly more effective than brief counseling [22]. Thus, the optimal extension of a brief intervention still seems to be unclear.

1.7

Problems with Dropout in Studies

Edwards and Rollnick have pointed to the problems with dropout – when the estimates of effect are based only on those who could be interviewed during followup examinations [12]. It is argued that this complicates the interpretation and generalizability of information from the brief intervention studies. The brief intervention studies published to date indicate that the positive results are achieved in studies which have been performed in the most suitable populations [12]. This is in agreement with our findings. The populations in the studies presented in this review usually consist of middle-aged heavy drinkers and problem drinkers (Table 1.2) who have been identified in primary health care and have been willing to accept the intervention. The only exception to this was the study by Elvy et al., which included younger heavy drinkers (mean age 29 years) [13]. In other studies, the mean age varies from 30 to 65 years (usually above 40 years). Another problem is that the persons who dropped out during the followup time probably differed significantly from those who stayed in the study. For example, in the study by Suokas, those who could not be followed up drank significantly more, had more problems with alcohol, and smoked to a greater extent than the rest [43].

1.8

Problems with Implementation

Though the effects of brief intervention have been shown in many randomized controlled studies, the method has only been used to a limited extent. The difficulties of incorporating brief intervention with the routines of primary care and motivating health care employees to perform new activities are obvious. After a single day of education followed by some supervision, 35 physicians and nurses identified only 45 suitable cases for brief intervention during 6 months [6]. The authors conclude that it is possible to educate health care staff in using brief intervention. However, better screening methods are needed for the early detection of problem drinkers. It is also possible that certain physicians and nurses may be reluctant to address alcohol problems. A recently published study from the United States found that 2.5 h of education for physicians in using brief intervention in association with a continuous support doubles the activity of the physicians in this area [2].

37

38


In a randomized controlled study from 1991, Goldberg et al. showed that it is possible to enhance both screening and brief intervention [18]. In this study, the screening was made as part of the normal patient admission routine. By means of a two-item screening form, the nurses succeeded in estimating the alcohol habits in 90% of their 1328 patients during 4 months. Of these patients, 36% had a hazardous level of alcohol consumption, and approximately 30% of these accepted a referral to an alcohol counselor. This is a good result as compared to the patients treated in the standard way by their physician. Of these, 20% were given a referral to alcohol counseling. The authors conclude that the number of patients given adequate alcohol counseling increases in routine use of screening for hazardous alcohol consumption.

1.9

Summary

Detection and treatment of early alcohol problems is potentially of great importance. Different short-term interventions were studied in 25 randomized studies involving over 9000 patients. Most of the studies were conducted in the Nordic and English-speaking countries. The interventions were delivered mainly in primary health care and were carried out by physicians or nurses. However, the design of optimal treatment remains unclear. More extensive interventions have not consistently resulted in greater treatment benefits. It is also uncertain whether the measures yield effects after more than 2 years or if the intervention must then be repeated. There are also difficulties in transferring the research results to routine health care. In most of the studies, a significant effect of a brief intervention on alcohol intake has been shown in followups for up to 2 years. The treatment effect is of the same magnitude as that achieved with many common medical treatments for chronic conditions.

Glossary

GGT ASAT ALAT MCV

An enzyme produced in the liver, often in greater amounts due to high alcohol consumption but sometimes for other reasons. An enzyme produced in the liver, sometimes in greater amounts in patients with high alcohol consumption. An enzyme produced in the liver, sometimes in greater amounts in patients with high alcohol consumption. The volume of the red blood cells. At times increased because of high alcohol consumption.

References

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in general practice for smokers and excessive drinkers in Australia and the UK. I. Interpretation of results. Addiction 1994; 89:35-40. Richmond RL, Anderson P. Research in general practice for smokers and excessive drinkers in Australia and the UK. II. Representativeness of the results. Addiction 1994; 89:41-47. Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995; 90:119-132. Romelsjö A, Andersson L, Barrner H, Borg S, Granstrand C, Hultman O, Hässler A, Källqvist A, Magnusson P, Morgell R, Nyman K, Olofsson A, Olsson E, Rhedin A, Wikblad O. A randomized study of secondary prevention of early stage problem drinkers in primary health care. Br J Addict 1989; 84:1319-1327. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM. Churchill Livingstone, Edinburgh, London 1998. Scott A, Anderson P. Randomized controlled trial of general practitioner intervention in women with excessive alcohol consumption. Drug Alc Rev 1990; 10:313-321. Senft RA, Polen MR. Brief intervention in a primary care setting for hazardous drinkers. Am J Prev Med 1997; 13:464-470. Seppä K. Intervention of alcohol abuse among macrocytic patients in general practice. Scand J Prim Health Care 1992; 10:217-222.

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1 Kolumnentitel

2

Psychosocial Treatment for Alcohol Dependence Sven Andréasson, Agneta Öjehagen

2.1

Introduction 2.1.1

Earlier Reviews

Numerous reviews on the effects of treatment for alcohol problems have been published since the 1940s [11, 37, 50, 55, 56, 68, 69, 91, 113, 117, 132, 137, 175]. The need for reviews has increased as treatment research has expanded and become increasingly difficult to overview. The current literature is extensive. A MEDLINE search of studies published from 1966 through 1999 on the treatment of alcohol problems yielded 22 870 studies. Limiting the search to randomized controlled trials (RCTs) yielded 722 studies. However, many of these studies focus exclusively on pharmacology, secondary prevention, or adolescents. 2.1.2

Assessing the Effects of Different Methods

The most extensive literature reviews are the Holder et al. study from 1991 and the further elaboration and expansion of this material by Miller et al. in 1995 [69, 117]. The latter analysis attempts to rank all treatment methods that have been studied in controlled trials. The rank is determined mainly quantitatively according to the number of studies where a particular method was found to yield better or poorer results than an alternative treatment. The magnitude of the effect was not calculated. Instead, it was estimated whether, and how well, an effect from a method could be demonstrated on a 4-grade scale. The strongest evidence is considered to exist if a method shows an effect in relation to (1) no treatment, or (2) better/equal effect than another method which has shown an effect in relation to no treatment, or (3) if adding a particular method to another method yields a better result than without this addition. If one method is compared to another, but a control group is lacking according to the alternatives mentioned above, the evidence is judged to be less Treating Alcohol and Drug Abuse. Edited by M. Berglund, S. Thelander, E. Jonsson Copyright c 2003 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim ISBN: 3-527-30682-X

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2 Psychosocial Treatment for Alcohol Dependence

strong. Results are based on changes in drinking habits and/or other measurements, during some period of the followup. Furthermore, particular value is attributed to methods that show results in at least two studies. Also, an attempt is made to adjust for the variations in study quality. The final result, the cumulative evidence score (CES), is an index value where the number of studies indicating effect is weighed together with the effect grade and quality scores. The CES score does not control for study size or the level of severity in the study population. Similar reasoning is used to assess the effects of psychological methods in general (including treatment for substance abuse). A distinction is made whether an effect has been demonstrated in comparison to no treatment or has yielded a specific effect, i.e., in relation to competing methods. In the latter case, one controls for factors common to all treatment, e.g., attention and expectation effects [30]. Furthermore, an emphasis is placed on replication in at least two studies performed by other researchers. Interpretation can be difficult, for example, when Miller et al. gives higher scores for studies where the control groups are not provided with any treatment, while comparisons between two established methods that show the same results are not given any score [117]. Although none of the studies is superior in relation to the others, this does not mean that they are lacking in effects. Furthermore, comparability problems arise when a specific treatment is compared to “standard treatment” since the information about standard treatment is often deficient compared to specific treatments that are well documented and supported by theory. Furthermore, the interest and commitment among those providing treatment according to a specific, often new, methodology may be higher than among those providing traditional treatment. Ideally, the effects of every method should be assessed using the same type of comparisons. A design using a control group which is not treated or placed on a waiting list is more difficult to apply to patients with moderate/severe alcohol problems. Miller’s scoring system therefore favors studies of patients with milder forms of alcohol problems [117]. This illustrates the difficulties in finding an appropriate placebo therapy within the area of psychosocial treatment. Hence, when a method appears to be superior it may be a function of what it was compared with. In an attempt to manage this problem (“level the field”), Finney et al. performed a new analysis of the original material from Holder [55, 69], attempting to evaluate both effect and study design. Furthermore, it considered several statistical factors such as number of tests performed, one- or two-tailed tests, and categorical or continuous data. An interesting finding is that Miller et al. ranking of studies changes only marginally in the analysis by Finney et al. [55, 117]. The only meta-analysis of treatment for alcohol problems (excluding brief intervention) so far was done by Vito Agosti [1, 2]. However, here the aim was not to identify which methods yield the best results. The Agosti analysis, which consists of two parts, aims instead to answer the questions of whether treatment for alcohol problems (regardless of method) leads to the patients reaching total abstinence and whether treatment leads to reduced alcohol consumption. The first question is

2.1 Introduction

answered negatively, the second affirmatively. However, the value of this analysis, certainly as regards an issue of central importance, is diminished by the limited sample of studies and by the meta-analysis technique (see discussion below on meta-analysis). 2.1.3

Methodological Deficiencies and Problems

The quality in the treatment literature has gradually improved. Five basic requirements should be made on alcohol treatment studies. First, the intervention itself should be described; e.g., the duration of treatment, the intensity of treatment (e.g., number of sessions per week), and the type of care setting (outpatient, inpatient) where treatment is given. Second, the patients studied should be described, e.g., demographic data, data reflecting the patients’ degree of alcohol dependence, their social situation, other substance use problems, prevalence of mental disorders/personality disorders, and their motivation to change. Third, the delivery of the treatment should be described, e.g., the competence of the caregivers, methods of quality assurance (manual-based treatment, videotaped sessions, supervision, followup) and the percentage of planned sessions that were actually carried out. Fourth, a presentation of results should contain data that enables the reader to estimate the magnitude of the effect (e.g., median values and standard deviations). It is desirable to show results concerning the drinking behavior itself (rates for total sobriety and rates of reduced consumption) and improvements in the life situation in a broad context (social situation, quality of life). Fifth, data should be provided which enables the reader to estimate a quality score of the study. Included here are the above-mentioned data on methods for randomization, principles for patient selection, diagnostic method, description of the control treatment and statistical method (e.g., number of performed tests, selection of one- or two-tailed tests, etc.) [118]. Nevertheless, many randomized studies that are published in the alcohol treatment field are deficient in some aspects, limiting their scientific value. When conducting literature reviews, these deficiencies lead to problems in interpretation, mainly due to poor comparability. 2.1.4

Treatment Methods

The methods used to treat alcohol problems can be divided into those directed mainly at 1. motivation to change 2. changing the problem behavior itself 3. methods that focus on factors behind drinking problems 4. general supportive counseling 5. treatment focusing on partners or family.

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Most treatment studies evaluate the effects of different methods that yield an (initial) change of drinking habits. Also, many studies address treatment or prevention of relapse. However, the literature is more limited concerning methods for motivating people to change and maintaining the changes achieved. 1.

Motivational methods These are methods that discuss perceived advantages and disadvantages of alcohol consumption, short-term and long-term consequences, risk situations for problem drinking and alternatives to alcohol. This type of counseling largely leaves the individual to deal with change on his/her own.

2.

Methods aimed specifically at changing drinking behavior These methods aim at identifying risk situations for problem drinking, finding strategies to deal with these situations, training aimed at changing problem drinking, and coping with internal and external stress factors of significance for problem drinking (these methods include variants of cognitive behavioral therapy methods, and 12-step treatment). These often involve active change efforts that focus on drinking behavior.

3.

Methods focusing on factors behind drinking problems These methods target substance abuse in relation to underlying factors. The methods involve dynamic-oriented treatment that include the patient’s life history to help understand the drinking problem, although treatment focuses on current problems, and interactional therapies directed at interpersonal problems which are presumed to increase the tendency to use alcohol. These methods do not directly focus on training to change the problem drinking itself.

4.

General supportive counseling These programs usually do not outline a focused strategy in relation to the problem behavior. A common theme is supportive counseling combined with social work interventions. Disulfiram treatment is also included in some cases. Increasingly, the focus is on circumstances surrounding problem drinking, including causes and consequences. The literature may describe these programs as “standard treatment”. Combinations of different measures are specified to a greater or lesser extent. These programs are usually not described as clearly as programs with methods specifically targeted at changing drinking behavior. The different supportive measures are described in varying detail and differ in their degree of structure.

5.

Treatment focused on partners and family This treatment approach consists of programs that involve the problem drinker and his/her partner together and programs aimed at partners or family members only.

2.1 Introduction

Section 2.3 (Results) presents an assessment of effects based on the method categories 1 to 5, where categories 1 to 3 and usually category 5 are called specific methods, i.e., theory-based and where the methodology is well described, while category 4 is reported as standard treatment. To a varying degree, treatment of alcohol problems can be combined with interventions on other life problems. These include counseling and interventions concerning employment, economy, relationships, health, and general support to prevent drinking. Psychosocial treatment is regularly included as a component in pharmacological treatment for alcohol dependence. Modern drugs reducing the desire to drink; mainly naltrexone and acamprosate (see Chapter 4) are usually combined with psychosocial treatment, e.g., cognitive behavioral therapy (CBT). Treatment research has been aimed at finding effective treatments and at developing guidelines to differentiate treatments considering variations in the problem profiles of drinkers, so-called matching. In some randomized studies, differential effects have been identified in secondary analyses, when effects were found in subgroups of patients with certain characteristics. Other studies have primarily investigated different matching hypotheses. Matching studies are presented separately in this report. 2.1.5

Treatment Effects

When discussing treatment effects, authors are usually referring to the effect of different treatment methods. However, the entire treatment context is of importance. Important components in addition to the method itself include the patients’ characteristics, the competence of the therapist, and the patient-therapist relationship. The method itself explains only a part of the outcome variance. This fact calls for study populations large enough to identify the treatment effects that can be specifically ascribed to the method. In addition, high demands on quality must be fulfilled, e.g., consistent application of the treatment methodology, which in turn calls for qualified supervision. Certain methods are easier to learn, e.g., brief interventions, while others place higher demands on therapist competence concerning both training and practice (e.g., cognitive behavioral therapy and interactional therapies). To assure methodological quality, studies have been relying increasingly on manuals. In psychological treatment, therapist quality, mainly the ability to empathize and achieve a working alliance, has also been shown to influence the results of treatment [15, 20, 71]. The therapist should be able to achieve collaboration with different patients. Awareness that this factor contributes to the outcome has prompted several treatment studies, e.g., Project MATCH, to include a measure of the working alliance [36].

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2.1.6

Questions Addressed

Does psychosocial treatment have an effect in comparison with no treatment? In this review, which is limited to randomized controlled studies, the effects of treatment methods are evaluated by comparing them either with no treatment or with another treatment. Studies that compare treatment with no treatment answer the question of whether a treatment method has any effect at all. These studies can be divided into four groups: 1. The comparison group is neither treated nor assessed. Even an assessment itself has an influence on the control group. Hence, these studies are limited to studies of natural courses and do not include a personal examination, e.g., register studies of health service utilization or mortality. This type of comparison is not included here. 2. The comparison group undergoes an initial assessment and followup examinations; it is informed about the study, but is not given any treatment. Even if no treatment is provided, such a study design has an influence on the control group. However, it is unclear how strong this influence is in different cases. 3. The comparison group is placed on a waiting list. The comparison is then limited to the time period defined by the waiting list, usually a few months. Also in this case, the comparison group is subjected to an initial assessment and followup examinations. According to the literature, however, a waiting list is considered to have a negative influence on the patient [86]. 4. “No treatment” also includes a comparison with minimal treatment, i.e., more extensive treatment is compared with one session of advice or feedback of results from the assessment. Are some methods superior to others? Comparisons with other treatments can be performed in several different ways. In principal, they can be divided into three categories:

1. Comparison with “standard treatment” 2. Comparison with another specified treatment, i.e., a treatment that is clearly theory-based and where the method is manual guided and supervised 3. Comparison that includes adding an extra treatment component in addition to a common primary treatment, for the study group. Comparisons can also be made between individual and group treatment based on the same treatment method.

2.1 Introduction

2.1.7

Intensity and Aftercare

A comparison may address the intensity of the same type of treatment program. This can be done in different ways. ● Minimal treatment contact, e.g., an occasional interview or an entire program ● Few or many sessions within the same program, e.g., 4 sessions compared to 12 sessions ● Short or long contact involving the same number of sessions in the same program, i.e., the duration of the program ● Therapist-managed or self-managed treatment. For this purpose, a manual of some kind is distributed. This type of treatment is sometimes called “bibliotherapy”. Comparisons between different types of care also concern the intensity of treatment. Here, studies will be presented which compare the effect from different forms of intensity; types of care (outpatient care, inpatient care) and the duration and extent of the methods (length of time, few or many sessions). In this context, studies on aftercare are also presented. Aftercare may take place in the form of a specific methodology, so-called booster sessions, or followup support contacts. 2.1.8

Subgroups of Alcohol Dependence

During the past decade, patients with alcohol dependence who have other concurrent diseases, mainly other psychiatric disorders, have received increasing attention since comorbidities influence treatment study designs and outcomes. Severe psychiatric conditions are often included among exclusion criteria in treatment studies. However, uncertainties exist in many studies concerning the occurrence of dual diagnoses, especially personality disorders. Only a few of the randomized controlled studies evaluate treatment methods in this group. Randomized studies identified in this area are presented in this chapter. Homeless alcohol-dependent patients have received increasing attention, and interventions for this group are evaluated in some randomized studies. Psychiatric and somatic comorbidity also occurs in this group. It is often discussed whether treatment results differ between men and women, and whether special methods should be used to treat women. This issue will be addressed where controlled studies present separate analyses for women and men, although this is uncommon.

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2.2

Method and Material 2.2.1

Search Strategies

This review is limited to randomized controlled trials. Using the keywords “alcoholism” and “randomized controlled trial”, a MEDLINE search yielded 722 studies through January 1999. Additional searches were performed in the NIAAA study base EtOH, and in Current Contents. Reference lists from earlier reviews and published studies were also reviewed. Unpublished dissertations and results published in books were not included in the analysis. Furthermore, the search was limited to studies describing results from psychosocial treatment of alcohol problems. Studies on pharmacological treatment, on treatment of adolescents, and secondary prevention (with certain exceptions for studies comparing treatment with no treatment) have been excluded. Ultimately, 139 studies were included. In March 2002, a renewed literature search was conducted (following the original publication of this report in Swedish in 2001). This search yielded an additional 25 randomized, controlled studies. The results from this renewed search are summarized in the last part of the results section. 2.2.2

Result Protocol

In addition to presenting numbers of patients and gender distribution, Tables 2.11 through 2.22 present problem severity based on a 3-grade scale, brief descriptions of the intervention and control groups, the duration of treatment, followup time, the percentage of patients followed up, methodological quality of the studies (Qscore), treatment results, and a summary of these factors. The foundation for these data varies considerably from study to study. Data are often missing concerning the characteristics of the patient and the delivery of treatment (e.g., therapist competence). A description of alcohol problems is the variable that appears most often in the studies, and it was deemed possible to categorize problem severity into three groups: mild = 1, moderate = 2, heavy = 3. The “mild” group (n=28) consists of populations not judged to be severely alcohol dependent, often referred to as “problem drinkers”. The “heavy” group (n=23) includes patients with severe complications from drinking, e.g., homelessness. Hence, most of the populations (n=88) have been categorized as “moderate”. The results nearly always present consumption specified in terms of total abstinence, controlled drinking, or number of drinking days. Some studies also discuss change in other problem areas. Observation periods and followup times vary. Confirmation of the results by family members or biochemical analyses is desirable, but often missing. Data on changes in drinking behavior served as a minimum requirement for studies to be included in this review. Total abstinence and controlled consumption, as outcome measures, have been subject to considerable debate. It is

2.3 Results

essential to describe whether the different methods achieve change in only one or in both of these parameters. Studies usually report only the percentage of those achieving complete abstinence, but less often present data on controlled consumption and changes in the percentage of drinking days. Also, treatment goals (which are not always stated) vary among the different studies. 2.2.3

Meta-analysis

Meta-analysis is used to combine results from different studies, giving consideration to variations in the size of the patient groups and the differences in confidence. This project was initially intended to estimate the effect sizes related to all treatment methods, largely because many studies were based on relatively few patients and therefore lacked sufficient statistical power to address the issues. Unreflective use of meta-analysis may lead to unreasonable conclusions due to heterogeneity in central variables. In many cases it was not feasible to perform meta-analysis in this review. To illustrate the potential of the meta-analysis method, smaller groups of studies with similar patient databases have been studied, however, following the meta-analytic procedures outlined in the introduction to this volume. Seven meta-analyses of this type were performed and are presented in the results section. The results are summarized in Table 2.10 and Figures 2.1 and 2.2.

2.3

Results 2.3.1

Does psychosocial treatment have any effect? Comparisons with no treatment

Studies that compare treatments with “no treatment” answer the question of whether these treatments have any effect, but do not specify the effect in comparison to other treatments. These comparisons do not control for several nonspecific factors surrounding all treatment, e.g., expectation of change or the importance of receiving attention. In the studies presented below, all patients were initially assessed, i.e., including those not receiving any treatment. Hence, a therapeutic effect from the assessment interview cannot be excluded. Sixteen studies were found (see Table 2.11a,b) of which 10 included comparisons with no treatment [23, 26, 33, 41, 66, 85, 99, 124, 131, 148]. Three of the studies included drunken drivers, of which two studies are lacking followup data concerning alcohol habits [23, 41, 99]. Six studies included comparisons with individuals on a waiting list for treatment [4, 14, 28, 51, 65, 116]. Comparison with no treatment Of eight studies (excluding the two drunken driver studies without data on alcohol habits) six included patients with a low problem severity [23, 26, 33, 66, 85, 124,

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131, 148]. Three of these show better results with intervention; two of the studies use behavioral therapy techniques and one uses physical exercise. Of the three studies [33, 66, 148] that do not show any differences, one [66] concerns intervention from primary care. In one study [23], the group is followed up on repeated occasions without intervention, and one study [148] shows an initial improvement after 3 weeks of intervention focused on coping with stress, which, however, is not sustained at 6-month followup. Two studies concern patients with a greater problem severity. One is a study of mentally impaired, homeless patients where a positive treatment effect was observed by the use of case management, with or without supportive housing, compared to no treatment [26]. The second is a smaller study that attempted to establish a counseling contact with alcohol-addicted social “outcasts” [131]. No effects could be observed from the intervention. Two of the three studies on drunken driving report no measures of consumption. One of the studies shows no difference in the rate of relapse in drunken driving or in time before arrest [41]. The second study investigated mortality after 8–13 years and found that people in rehabilitation tended to have lower mortality and a lower rate of death from accidents and violence. A small study compared standard treatment after drunken driving with education directed toward controlled consumption and no intervention, respectively. It was found that better psychosocial adjustment was achieved in the first two studies, and that the group receiving treatment aimed at controlled consumption had a significant reduction in the number of occasions of uncontrolled consumption [41, 99, 23]. Comparison with waiting list It should be noted that waiting lists generally are valued negatively in the treatment literature. Of the 6 studies found, 5 show poorer results for people on a waiting list, regardless of method and intensity, compared to people treated. In the study showing no difference, patients were asked to record and report their consumption during the waiting time and take Antabuse. After 4 weeks they were admitted for inpatient care as promised [51]. Meta-analysis 1: Treatment versus no treatment A problem in this analysis, as in most others, is which inclusion and exclusion criteria to apply. Table 2.11a presents 10 studies which include comparisons with no treatment. To be included in meta-analysis, the studies must contain comparable outcome data on alcohol consumption. When effect sizes were calculated and an attempt was made to include them in a meta-analysis, they were found to be highly heterogeneous. To achieve homogeneity, the analysis was therefore limited to studies with similar problem severity. Given these limitations, only 3 studies remain. One problem is that different studies use different outcome measures and different followup periods. Hence, Kivlahan reports the number of drinks per week at 4 and 8 months, respectively [85]. A mean value was then calculated for 6 months. In the two other studies, one reports number of drinks per month (at 6 month’s followup) and the other percentage of days with uncontrolled drinking after 6 months [66, 23].

2.3 Results

Meta-analysis 2: Treatment versus waiting list Five of the six studies found are included. (The study by Eriksen was excluded because of missing alcohol data [51]). Here, a new study, identified in the renewed literature search 2002, was included (Kelly et al., 2000 [184]), bringing the total to six studies. Problem severity is generally low, but is in some cases moderate. Followup periods and outcome measures vary: Miller follows the subjects for 6 weeks and measures drinks per week, Harris follows for 2.5 months and measures improved drinking patterns, Alden follows for 3 months and measures how partners who are abusive drinkers reduce their alcohol consumption, Cadogan follows for 6 months and measures the percentage of completely abstinent patients, and Kelly follows for 4 weeks and measures the level of alcohol consumption [116, 65, 4, 14, 28, 184]. This group of six studies was sufficiently homogenous for meta-analysis. Meta-analysis 3: More extensive treatment compared to a single interview Six studies were found in the original literature search. Most concern patients with moderate problem severity. Comparison treatments are mainly standard treatments without any specific focus. The study by Edwards reports on the number of completely abstinent weeks during one year, at 12-month followup [47]. Chick reports on the percentage of patients without alcohol problems after 2 years [32]. Zweben reports on the percentage of days of moderate drinking at 12 months [181]. Bennie reports on the number of completely abstinent weeks after 6 months [16]. Chapman reports on the percentage of completely abstinent subjects at 18 months, and Sannibale reports on the percentage with improved drinking patterns after 15 months [31, 154]. In the renewed literature search, a seventh study was identified, where Sellman (Sellman et al., 2001 [185]) reports on the rate of abstinence after six months of followup. Results from meta-analyses 1–3 Three studies that compared treatment with no treatment at all found an overall weighted effect size (ES) of 0.27 (meta-analysis 1; d, fixed model). Studies that used patients on waiting lists for comparison reported greater treatment effects, d=0.66. For those who are alcohol dependent, more extensive treatment yields better effects than an occasional interview, d=0.22. Combining these three analyses, an overall effect size of 0.37 was obtained (random model). All three meta-analyses were individually negative for heterogeneity, but the combined analysis was positive, calling for a random model. Comment The results from meta-analysis 3 may seem surprising in the light of some of the treatment literature. Several of the studies, in particular the classic study by Edwards, have been generally perceived to indicate that the extent of treatment has no significance [47].

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Summary The psychosocial treatment literature contains only a few studies that compare treatment to no treatment. Generally, treatment is observed to be effective. In the studies that found no difference between treatment and no treatment, it cannot be excluded that the assessment itself may have had a positive influence. For alcoholdependent individuals, more extensive treatment has a better effect than a single treatment session. See also Section 2.1.7, which describes studies that compare the duration of treatment in outpatient care, e.g., comparing more extensive treatment to a single interview. 2.3.2

Are some methods superior to others?

The effects of most of the treatment methods are evaluated by comparing with other treatment methods. Specific treatments are compared either with standard treatment or with other specific treatments. The effect of standard treatment as an independent intervention is rarely evaluated.

2.4

Motivational Methodology (see Table 2.12)

The motivation studies report effects from motivational interviewing and motivation-enhancing treatment. This section also includes studies comparing the effects of self-treatment (bibliotherapy) with therapist-managed treatment. Motivational interviewing of somewhat varying design has been analyzed in three studies (see Table 2.12a). All three studies were designed to give patients in the study group one or more motivational interviews in addition to their regular treatment. Two of these studies are of high methodological quality and report positive effects [18, 24]. No effect was found in the third study [88]. This study, which has a lower methodological quality, is aimed at physically “worn out” alcoholics and raises questions whether the interviews fulfill the criteria for “motivational interviewing”. Apart from these three studies, promising results are reported from a study in a maternal health clinic where pregnant women were randomized to either a motivational interview or to standard treatment [64]. High-consuming (but not alcoholdependent) women reduced their consumption more when they participated in motivational interviews. Meta-analysis 4: Motivational interviewing Only three studies could be included in this meta-analysis, one of which was borderline [88]. In the first two, the effect from adding a motivating interview prior to standard treatment is compared to not doing so [18, 24]. Problem severity is moderate except in the study by Kuchipudi, where it is substantial [88]. All the studies have short followup times (3 to 4 months) and all use alcohol consumption/sobriety as outcome measures.

2.4 Motivational Methodology

Adding a motivational interview to other planned treatment yields better results, ES = 0.26. A substantial difference can be noted between two positive studies, well supported by MI methodology, and a third, negative study. The ES in the first two studies was 0.78 and 0.70, respectively, while ES in the third was 0.02 [18, 24, 88]. In the study by Kuchipudi, where the intervention is performed with patients hospitalized for somatic disease, the motivational intervention seems more focused on persuasion than actual “motivational interviewing” as suggested by Miller and Rollnick [88, 114]. Brief CBT-focused counseling that involves motivational methodology was addressed in five studies (see Table 2.12b) [151, 152, 154, 116, 170]. In comparison with more extensive treatment, no difference in results can be observed, i.e., brief counseling has the same effect as more extensive treatment. In comparison with a waiting list, however, better results are observed [116]. Heather reports from two studies performed in English primary care (see Table 2.12c). One study found no effect from counseling alone compared to no treatment [66]. All patients, however, underwent initial assessment, which must be considered to be a significant confounder. Furthermore, only a small proportion of the counseling group completed the intended program. In the second study, patients were offered a self-help manual and varying levels of telephone support [67]. No difference in effect was observed with different levels of telephone support, but alcohol consumption decreased in all intervention groups compared to a control group that only received a brochure. The value of a self-help manual, or bibliotherapy, has been analyzed in five studies (see Table 2.12d) [111, 112, 151, 65, 152]. All five studies report that bibliotherapy had the same effect as 6–10 therapist-managed treatment sessions. The patients in these studies consistently had less severe alcohol problems. A comparison between bibliotherapy (specific instructions to reduce alcohol consumption) and general alcohol information demonstrated a significantly better effect from bibliotherapy [167]. Meta-analysis 5: Bibliotherapy. Five studies are included, all of which describe patients with limited problem severity. The comparison treatments are all CBT programs with a focus on training of self-control. Sanchez-Craig measures complete abstinence or moderate drinking after 12 months, and the study is replicated in 1991 [151, 152]. Miller measures alcohol consumption at 3-month followup and describes improvements in the drinking pattern after 8 months [112, 113]. Harris describes improvements in the drinking pattern after 15 months [65]. The intervention consists mainly of written self-help material and includes 1–3 interview contacts [65, 112, 113, 151, 152]. For patients with limited alcohol problems, occasional interviews in combination with self-help material appear to yield an effect the same as or better than traditional therapist-managed treatment; ES = 0.19 (see meta-analysis 5). The analysis here is limited since all studies have been performed with a CBT focus aiming at self-control training. However, the results are consistent, and all studies point in the same

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direction. In these studies, bibliotherapy and therapist-managed treatment seem to be equally effective. Combining the studies in meta-analyses 4 (motivational interviewing) and 5, both of which describe limited treatment measures, results in an overall weighted ES of 0.32. Motivational enhancement treatment, MET, is evaluated in two randomized studies (see Table 2.12e) [143a,b]. In “Project MATCH”, no effect difference is found between 4 sessions of MET and 12 sessions of CBT, while 12-step treatment shows a somewhat higher proportion of sober persons [144, 147]. Robertson, however, reports a significantly better effect from CBT treatment than that from MET [147]. Both studies have problems in interpretation. Thus, in “Project MATCH” the MET patients met the evaluators more often than their therapists during the 18 months of followup. The frequent followup probably had an equalizing effect on the results. Robertson’s study, on the other hand, was very small, only 37 patients. To some extent, it appears that the poorer results in the MET group can be attributed to three patients. Summary Motivational interviewing increases the effect of another treatment, but has not itself been subjected to randomized study. Brief, motivation-enhancing treatment appears to have the same effect as more extensive treatment. The effect of bibliotherapy is the same as or better than that of therapist-managed treatment for patients with a low level of alcohol dependence. The studies, with the exception of “Project MATCH”, have mainly recruited patients with a lower level of alcohol dependence.

2.5

Methods Specifically Aimed at Changing the Drinking Problem Itself 2.5.1

Cognitive Behavioral Therapy (CBT) (see Tables 2.1 and 2.13a–e)

The CBT studies involve a number of different techniques that share the feature of combining learning theory and behavioral therapy. However, pure behavioral therapy is rarely applied and is usually combined with cognitive methods. The CBT methods generally emphasize direct changes in behavior. CBT methods include training in coping with psychosocial stress factors, “coping skills”, often with special training for social skills (under the assumption that deficient social skills increase the risk for problem drinking), identification of risk situations for problem drinking, and training strategies to handle these, techniques for improved impulse control, training in techniques to control alcohol intake, management of relapse “relapse prevention”.

2.5 Methods Specifically Aimed at Changing the Drinking Problem Itself

This report groups the CBT literature into five categories: 1. Broad spectrum treatment with a CBT focus 2. CRA treatment (Community Reinforcement Approach) 3. Self-control training 4. Cue exposure 5. Other methods (anxiety treatment and self-confrontation by means of video recording) The outcome of the CBT studies is dependent on which type of comparison is made. In the studies that compare an experimental CBT treatment to “standard treatment” [5, 13, 23, 120, 125, 134, 163], a majority of studies report positive results (four out of seven). This is contrasted with the studies that compare the experimental treatment to another specific treatment where a smaller share of studies (five out of fifteen) report positive results [5, 13, 36, 44, 54, 77, 80, 92, 109, 110, 119, 134, 136, 143, 144, 153, 159, 160, 182]. In two studies, negative results are found compared to other specific treatment: 12-step treatment and dynamic/interactional therapy [143, 153]. 2.5.2

Broad Spectrum Treatment with CBT Focus

Broad spectrum treatment involves different combinations of measures directed both to the dependence condition in itself and to several psychosocial problems with which alcohol dependence is associated. Here are included, e.g., different forms of “relapse prevention” and “coping skills training“ (see Table 2.13a). Twelve studies belong to this group. Most have recruited patients with severe dependence disorder and/or complicating psychosocial conditions. Most studies have followup periods of at least 12 months. In none of the two studies comparing broad spectrum CBT with standard treatment are better results achieved at 12 months of followup [5, 125]. However, Allsop finds clearly better results from CBT treatment at 6 months, results which however do not persist at 12 months [5]. The author notes that for the heavy group of patients which this concerns, greater attention must be given the factors in the community environment (unemployment, relationship problems, etc.) which increase the risk of relapse. Among the studies where comparison is made with another specified treatment, positive results are achieved in two cases. One of the studies is performed by Ferrell, who finds better two-year results for broad spectrum CBT than a variant of interactional therapy “human relations training” [54]. The second is made by Monti, who finds better results with a broad treatment program focused on communication training compared to a more psychologically directed treatment to handle negative affect and alcohol craving [119]. Six studies find no differences in comparison with other specific treatment. Several of the comparisons are made with less extensive treatment and confirm the above observation that more extensive treatment generally does not yield better results. In Project MATCH, 12 sessions of “Cognitive behavioral coping skills” are compared with 4 sessions of “Motivational

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58

2 Psychosocial Treatment for Alcohol Dependence Table 2.1.

Studies of CBT treatment.

Study

Nelson 82/83 [125] Allsop 97 [5] Olson 81 [134]

Comparison treatment

Standard treatment Standard treatment Standard treatment (environmental therapy) Project MATCH [143] Other specific treatment: 12-step and MET, respectively Ferrell 81 [54] Other specific treatment: Human relations training Miller 80 [110] Other specific treatment: Self-control training Skutle 87 [160] Other specific treatment: Self-control training (bibl. or therapist-managed) Kadden 89/ Other specific treatment: Cooney 91 [80, 36] Interactional therapy Litt 92 [92] Other specific treatment: Interactional therapy Ito 88 [77] Other specific treatment: Interactional therapy Monti 90 [119] Other specific treatment: CBT mood management Öjehagen 92 [182] Other specific treatment: Dynamic/interactional therapy Sandahl 98 [153] Other specific treatment: Dynamic/interactional therapy Sjöberg 85 [159] Other specific: Dynamic therapy Miller 80 [110] Combination with self-control training Skutle 87 [160] Combination with self-control training Monti 90 [119] Addition to individual communication training O’Farrell 93 [129] Addition after marital therapy Graham 96 [63] Group – individual

Effect

Problem severity

Followup ≥12 months

1=2 1=2 1>2

3 3 2

+ + +

12

2

+

1=2

1

+

1=2

1

+

1=2

2

+

1=2

2

+

1=2

2

–

1>2

3

–

1=2

2

+

12 1=2

2 2

+ +

Enhancement Treatment” (MET) and with 12 sessions of “Twelve-step facilitation therapy” [143]. Both Miller and Skutle compare broad spectrum CBT with more limited self-control training [110, 160]. Kadden and Cooney (same study) as well as Litt and Ito report no basic differences between the results from CBT and interactional therapy, even though interesting matching effects are found (see below) [36, 80, 92, 77]. In four studies, the effects of adding more extensive broad spectrum CBT to other CBT treatment are compared, either in the form of enhancement during ongoing treatment or in the form of addition after basic treatment has been provided. In three cases out of four, this did not yield better results. The exception is O’Farrell, who finds that addition of relapse prevention during one year after behavioral marital therapy (which itself has a positive effect) yields a better effect [129]. Monti did not find any additive effect from involving one partner in a CBT-focused treatment


program with emphasis on communication training [119]. Miller saw no differences in results in the comparison between broad spectrum CBT and self-control training (either in bibliotherapeutic or therapist-managed form) or self-control training enhanced by relaxation training, communication training, and training in self-assertion [110]. Skutle did not achieve better results by adding more extensive CBT treatment to self-control training, whether this was performed in bibliotherapy form or in therapist-managed form [160]. In a comparison between individual treatment and group treatment with CBTfocused relapse prevention, Graham found no difference between the results, and both groups improved markedly [63]. This study also compared giving relapse prevention as followup treatment to two greatly differing primary treatments: residential 12-step treatment and relatively unspecific “eclectic” treatment in outpatient care. Nor in this comparison were any differences observed. Meta-analysis 6: cognitive behavioral therapy Six studies are included in this analysis (see Figure 2.2) and mainly involve patients with major problem severity. These studies use broad-spectrum treatment with a CBT focus and different methodological foci, e.g., relapse prevention and cue exposure. The comparison treatments consist of different forms of standard treatments, in some cases with focus on self-confidence training or relaxation training [44, 54, 125]. The followup periods in these studies are all 6 months, except in the Nelson study which has a followup period of 2 months. In most studies the outcome measure is total abstinence, but not in the Allsop study which measures improved drinking patterns, nor Drummond who uses an alcohol problem index [5, 44]. The combined effect size (d, fixed model) was 0.73. Summary Only a few studies compare broadly designed CBT treatment with standard treatment for patients with extensive alcohol problems. The meta-analysis of these studies shows positive effects. However, positive effects in short term followup decrease at 12-month followup. In comparison with other specific treatment, no better effect is found. 2.5.3

CRA Treatment – Community Reinforcement Approach (see Tables 2.2 and 2.13b)

In CRA treatment, principles for operant behavior modification are combined with social system theory, where aspects of the local community are used to award behavioral change. Natural obstacles to drinking are expressed in operant terms. The probability that the patient will resist drinking increases if it jeopardizes other sources of satisfaction. Sobriety-enhancing factors are searched in relationships with partners or other family members, working life, leisure activities, etc. Seven randomized studies in the alcohol area have been found. The first were based on small samples of 16, 18, and 43 patients [9, 10, 74]. However, the effects were large concerning both drinking behavior and social adjustment. In a later, methodologi-

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Studies of CRA treatment.

Study


Effect

Problem Followup severity ≥12 months

1. Azrin 76 [9] 2. Azrin 82 [10] 3. Hunt 73 [74] 4. Smith 98 [162] 5. Sisson 86 [157] 6. Mallams 82 [98] 7. Miller 92 [115]

Standard treatment Standard treatment Standard treatment Standard treatment Standard treatment Standard treatment Other specific treatment (12-step treatment) Other specific treatment: Antabuse

1>2 1>2 1>2 1>2 1>2 1>2 1=2

2 2 2 3 2 2 2

+ – – + – – +

1>2

2

–

8. Azrin 82 [10]

cally more ambitious study, Miller finds no advantage of CRA treatment compared to 12-step treatment [115]. In a study of homeless persons, Smith reports that CRA has better effects on drinking behavior than the usual 12-step treatment; however, no differences concerning social adjustment are observed [162]. Furthermore, certain CRA components have been particularly investigated. A study of the social club (which is one such component) found that a group who received support to participate in the activities of the club had significantly better results regarding both drinking habits and social function than a group which did not receive such support [99]. In similar ways, Sisson studied the effect from involving a partner or other family member in a CRA program [157]. Significantly more people with alcohol problems whose partners were included in the study group sought treatment compared to the control group, and they reduced their alcohol consumption considerably more. The scientific basis of the CRA treatment is limited by the fact that the same group of researchers in the United States has performed most of these CRA studies. The generalizability from the earlier studies is limited by the fact that CRA was consistently compared with poorly defined standard treatment and where the CRA therapists in some cases also performed the control treatment. Therefore, it should be noted that when a comparison is made with another specific treatment – a 12-step programme – no advantages of CRA treatment are found. Meta-analysis 7: CRA treatment Seven studies are included in the analysis. The patients are alcohol dependent with a moderate to high problem severity. All of the comparison therapies use some variation of 12-step treatment. The older studies, however, apply a poorly defined standard treatment. Only one study draws a comparison with a qualified form of 12-step treatment [115]. Most report followups at 6 months. Mallams, however, reports at 3 months, Sisson at 5 months, and Miller at 12 months [99, 157, 115]. The outcome measures vary; e.g., Hunt and Azrin measure the time the patient drinks alcohol [9, 74]. Azrin measures number of drinking days and Mallams reports reduced drinking [10, 99]. Sisson uses as a measure the share of drinking partners who reduce their drinking as a consequence of an intervention for family members; Miller and


Smith use alcohol consumption per week [115, 157, 162]. From these seven studies a significant ES of 0.59 is seen. The original CRA studies made comparisons with standard treatment and yielded very large effect sizes (between 1.07 and 1.56) [9, 10, 74]. When a comparison is made with another specific, manual-based treatment (like 12-step treatment) no superior effect is achieved, ES = 0.06 [115]. Summary CRA treatment shows a better effect than standard treatment, but the same effect as other specific treatment. It represents a treatment alternative for patients with severe alcohol dependence. 2.5.4

Self-control Training (see Tables 2.3 and 2.13c)

Effects from CBT-focused, self-control training are described in 11 randomized studies. Self-control training is treatment that aims at giving the patient better control over his/her alcohol consumption. Both training in identifying, avoiding, or mastering risk situations for problem drinking and training in controlled intake are included. Usually the goal is not to achieve complete abstinence. The goal is to keep the blood alcohol level below a certain limit, e.g., of 0.8‰, mainly by keeping the consumption rate down. Here are not included studies which have trained patients in laboratory-similar environments with or without aversion techniques (e.g., by provoking nausea, pain, or apnea). Mainly patients with relatively limited alcohol problems have been recruited to these studies. An important exception is the Foy study where patients with a high degree of alcohol dependence were recruited [60]. Apart from a broad CBT program, the study group, but not the control group, received training in controlled drinking. The result at the 6-month followup was considerably poorer for the study group. At 12 months, however, no differences were observed. Thus, self-control training seems contraindicated for this group, although the damage is possibly limited by the natural course. This finding can be compared with the results from Sobell’s classic study of 1973, where it was found that behavioral therapy with controlled drinking as a goal yielded results equally as good as behavioral therapy with complete abstinence as a goal [163]. In the Sobell study, the treatment was classic behavioral therapy with aversion treatment as the central element. The results from the Sobell study were criticized by Pendery, who reported that all patients in Sobell’s study, except one, either became totally abstinent or went back to heavy drinking [138]. Three studies compare self-control training to no treatment [23, 66, 65]. Heather finds no effect [66]. In the two other studies, a positive effect is reported [23, 65]. However, Heather’s study holds some reservations. This study had the character of a “brief intervention” in primary care and consisted of only two conversations. Furthermore, in the majority of cases the patients did not receive the intended treatment.

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62


Studies of self-control training.

Study

1. 2. 3. 4. 5. 6.

Brown 80 [23] Heather 87 [66] Harris 90 [65] Brown 80 [23] Baker 75 [13] Caddy 76 [27]

7. Miller 78 [109] 8. Foy 84 [60] 9. Foy 84 [60] 10. Miller 80 [111] 11. Skutle 87 [160] 12. Miller 81 [112] 13. Harris 90 [65] 14. Duckert 92 [45]


Effect


No treatment No treatment Waiting list (+ assessment) Standard treatment Standard treatment Other specific treatment: aversion treatment Other specific treatment: aversion treatment Addition to broad spectrum CBT Addition to broad spectrum CBT Bibliotherapy – therapist-managed treatment Bibliotherapy – therapist-managed treatment Bibliotherapy – therapist-managed treatment Bibliotherapy – therapist-managed treatment Group-individual treatment

1>2 1=2 1>2 1>2 1=2 1>2

1 1 1 1 2 2

+ – + + – +

1=2

2

+

1=2 12

3

–

1>2 1>2

2 1

– –

Monti 93 [120] Sitharthan 97 [158]

ing, conditioned through long-term high consumption. Previous studies have clarified that exposure leads to stronger physiological reactions such as increased salivation and sweating in alcohol-dependent individuals compared to nonalcohol dependent. However, only a few clinical studies have been performed with cue exposure, and only three randomized studies are reported in the literature. These are all small studies with a limited duration of followup and can be viewed as developmental studies. Since they all report positive results, even though they were compared with different types of treatments (relaxation treatment, regular CBT, standard treatment) and recruited patients of various problem severity, the method should be considered as promising and lead to further study. 2.5.6

Other

The heading “other” includes a study that compared CBT-directed treatment for anxiety (under the assumption that the patients’ alcohol problems are associated with an elevated anxiety level) with more traditional relaxation training [136]. No difference in the results on alcohol consumption was found, but CBT reduced anxiety more than the other alternatives did. A study where patients are confronted with their behavior under intoxication via video recordings shows no effects compared to standard treatment [13]. Nor is any difference in effect found in a comparison with self-control training in the same study. 2.5.7

Twelve-Step Treatment (see Tables 2.5 and 2.14)

This section includes four studies with a total of 2045 patients where 12-step programs are evaluated (see Table 2.14). Treatment is based on the philosophy of Alcoholics Anonymous, including the concept of alcoholism as a disease. Twelvestep treatment is given as specific treatment and these studies do not include support by participation in AA meetings only. Twelve-step treatment is compared with both standard treatment and other specific treatments. In two of the studies the treatments are given individually and in outpatient care, while the Keso study describes inpatient care [84, 115, 143]. One study that includes patients who had both alcohol and cocaine dependence shows results only at the end of the treatment [29].

63

64


Comparison with standard treatment (2 studies) Both studies show better results from 12-step treatment. Keso compared with standard treatment in inpatient care and Carroll compared with general support via “case management” in cocaine- and alcohol dependence [84, 29]. The study by Keso also showed that more patients remained in the 12-step treatment, the treatment environment of which was perceived as more involving, supportive, and promoting problem solving than the traditional treatment [84]. Comparison with other specific therapy (3 studies) In Carroll’s study, a comparison is also made with CBT and furthermore with and without addition of disulfiram, where no differences exist between 12-step treatment and CBT [29]. The Project MATCH study, the aim of which was to test different matching hypotheses, also compared the results obtained using the three included specific treatment methods: cognitive behavioral therapy (CBT), motivation-enhancing therapy (MET), and 12-step treatment [143]. The treatments were given in outpatient care and approximately half of the patients had initially received inpatient care. The three methods achieved similar results, but a somewhat higher proportion of those patients who had not received initial inpatient care were completely abstinent after the 12-step treatment. In the study that compares 12-step treatment with CRA in outpatient care, the same results are achieved with 12-step treatment as with CRA [115]. As mentioned above, support via self-help groups (AA) is not included under this heading. In several studies, participation in AA groups is included as a component of standard treatment. In one study, AA group participation has been compared with different treatments, e.g., the study which compares inpatient care with outpatient care intervention in the form of AA group participation three times per week during one year (see Intensity [177]). This study reported poorer results from AAparticipation alone compared with patients who received AA support after initial treatment in inpatient care. In summary, 12-step programs show better results than standard treatment. Compared to other specific treatment the same results are found, however, with a somewhat higher share of totally abstinent.

Table 2.5.

Studies of 12-step programs.

Study


Effect Problem Followup severity ≥ 12 months

1. Keso 90 [84] 2. Carroll 98 [29] Carroll 98 [29] 3. Proj. match 97 [143] Proj. match 97 [143] 4. Miller 92 [115]

Standard (IP) General support, case management (OP) Other specific treatment: CBT (OP) Other specific treatment: CBT/MET (OP) Other specific treatment: CBT/MET (IP) Other specific treatment: CRA (OP)

1>2 1>2 1=2 1>2 1=2 1=2

OP = Outpatient, IP = Inpatient

2 2 2 2 2 2

+ – – + + –

2.6 Methods Aimed at the Factors Behind Alcohol Dependence

2.6

Methods Aimed at the Factors Behind Alcohol Dependence (see Tables 2.6 and 2.15a–c)

Nine studies are included in this section (see Table 2.15), three of which are based completely or partly on the same material; a total of 514 patients. This concerns methods focusing on factors behind the alcohol problem, early or present, which may influence the tendency to use alcohol. These treatment methods do not involve any direct training in changing the drinking behavior itself. Experimental treatment is compared in two studies with standard treatment and in the others with other specific methods. Two additional studies are presented in this section. These are early studies that evaluated “psychotherapy” in relation to standard treatment, e.g., with Antabuse [25, 180]. The content of psychotherapy is unclearly described and the theory support not stated. It is possible that they do not differ methodologically from the unclearly specified supportive therapies they are compared with. 2.6.1

Dynamically Oriented Treatments

Studies of classical dynamic therapies, with the main focus on interpretations of defenses and the significance of underlying conflicts for the alcohol problem, are lacking. In the four studies (see Table 2.15a) which have been reviewed, treatments with a dynamic focus, of which three hold comparisons with other specific therapies, are compared with standard treatment. The methodological quality is lower in the older studies. However, the duration of the followup is usually over one year. Comparison with standard treatment An early study of inpatient care randomized patients to environmental therapy in addition to transaction analysis (TA), behavioral therapy, or TA + behavioral therapy, and compared these to milieu therapy alone [134]. The transaction analysis (TA) is described as a form of insight-oriented psychotherapy combining psychodynamic and interpersonal principles with communication theory. Comparison with other specific therapies In Olson’s study, the TA therapy shows poorer results when it is compared with other specific treatment, e.g., behavioral therapy [134]. These differences exist at 6 months and at 18 months, but not after 4 years. Another three studies make comparisons with other specific therapies, cognitive behavioral (group therapy), and individual behavioral therapy, respectively [153, 159, 182]. The studies by Sandahl and Öjehagen involve more structured interactional elements with focus on the drinking behavior [153, 182]. Sandahl’s study of group therapies shows better results for the dynamic therapy [153]. The other two studies find no differences. In Öjehagen’s study, matching results in relation to the personality structure are found (see Section 2.8) [182].

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66


Methods aimed at the factors behind alcohol dependence.

Study


Effect


1. Olsson 81 [134] Olsson 81 [134] 2. Sandahl 96 [153] 3. Sjöberg 85 [159] 4. Öjehagen 92 [182]

Standard, environmental therapy (IP) Other specific treatment CBT (IP) Other specific treatment CBT (OP) Other specific treatment CBT (OP) Other specific treatment: behavioral therapy (OP)

1=2 12 1=2 1=2

2 2 2 2 2

+ + + + +

1=2

2

+

1=2 1=2

2 2

+ –

1=2 1=2

2 2

+ +

Interactional 5. Kadden 89/ Other specific treatment CBT (OP) Cooney 91 [80, 33] 6. Litt 92 [92] Other specific treatment CBT (OP) 7. Ito 88 [77] Other specific treatment: relapse prevention (IP) Other “psychotherapy” 8. Bruun 62 [25] Standard: Antabuse (OP) 9. Zimberg 74 [180] Standard: medication, Antabuse, support (OP) OP = Outpatient care, IP = Inpatient care

Interactional therapies Interactional therapy (see Table 2.15b), focusing on current relationships, has been tested as group therapy in three studies and was compared with other specific therapies, cognitive behavioral therapy, and relapse prevention. Two studies are based on the same study population. They both report results at the termination of the treatment and after 18 months of followup [36, 80]. A third study is based on the same population, but investigates male subjects only [92]. Furthermore, an inpatient care study is reported [77]. There are no overall effect differences between the interactional and the other specific therapies. However, the studies by Cooney and Litt report matching effects based on the degree of mental disorder (see Section 2.8) [36, 92]. Other dynamic therapies The focus of the two older therapies is unclearly described. They show no effect in comparison with standard/Antabuse treatment [25, 180]. The number of sessions is greater in these therapies. These studies receive lower quality scores than the other psychotherapy studies. Summary Studies of classic dynamic therapies for alcohol problems are lacking. Few differences appear in studies that compare modern dynamic, interactional therapies to other specifically focused therapy. Transactional analysis shows poorer effects than other specific treatment. Matching effects between type of therapy and patient characteristics appear in some studies. Here, therapies aimed at factors behind depend-

2.7 Standard Treatment

ence appear to be less suitable in treating patients with more severe mental disorders compared to treatments that actively focus on abusive drinking behavior.

2.7

Standard Treatment (see Tables 2.7 and 2.16)

These methods are also referred to as nonspecific treatment, in that they usually do not contain any focused strategy in relation to the abusive drinking behavior and are often less well described than the specific, theory-supported methods. A common approach is supportive counseling in combination with social work interventions. In some cases, disulfiram treatment is also included. This group includes 19 studTable 2.7.

Study

Standard, generally supportive treatments. Comparison treatment

1. Ogborne 79 [131] No treatment Other support/extent 2. Baker 75 [13] Counseling + video confrontation + role play 3. Gilbert 88 [62] Active contact telephone/house (call) in outpatient care 4. Pittman 72 [139] Unspecific treatment: Antabuse, medication 5. Powell 85 [142] Antabuse + medication/followup of physical health only Specific treatment 6. Allsop 97 [5] Relapse prevention: with or without role-playing 7. Azrin 82 [10] Antabuse supervision by family members/CRA 8. Azrin 76 [9] CRA 9. Carroll 98 [29] CBT+disulfiram/12-step + disulfiram 10. Eriksen 86 [52] Social skills training 11. Hunt 73 [74] CRA 12. Jones 82 [79] Discussion group/social skills training 13. Keso 90 [84] 12-step 14. Monti 93 [120] Addition cue exposure + coping skills 15. Nelson 82-83 Increase self-confidence. [125] Role play/demonstration 16. Pomerleau 78 Behavioral therapy [140] 17. Sannibale 88 Cognitive therapy/min intervention [154] 18. Sobell 73 [163] Behavioral therapy controlled consumption/total abstinence 19. Telch 84 [173] Symbolic aversion technique/control

Effect

Problem severity

Followup ≥12 months

1=2

3

–

1=2

2

+

1=2

2

+

1>2

2

+

1=2

2

+

12>3

8–13 years

18

Followup mortality 1. 7.7% vs 2. 11% (tendency) – accidents, violent death 12 survival (ns)

Table continues on next page

92

2 Psychosocial Treatment for Alcohol Dependence Table 2.11a. (cont.) Study

Population

PS1

Treatment

Duration

Murphy [124] 1986

N=60 All men, collegestudents

1

1. Physical exercise (running) 2. Medication 3. No treatment

8w

Ogborne [131] 1979

N=40 Homeless men

3

1. Counseling 2. No treatment

max. 6 months

Rohsenow [148] 1985

N=36 Men only, collegestudents

1

1. Stress management 2. No treatment

3w (total 6 h)

1)

PS: Problem severity (1 = slight; 2 = moderate; 3 = severe).

2.14 Renewed Literature Search

93

Followup

Quality score max. 27

Outcome

Effect

6 w; 31/60. 52% 1=9 2=9 3=13

18

Significantly less consumtion group 1 compared to 3 w 3–6 and 7–70 Group 2 no significant difference 1 or 3

1>3

3 months 16/20=80% 12/20=60%

14

No differences

1=2

5–6 months

21

Significant reduction consumption baseline – 2,5 months followup in experimental group, but not in control group Return baseline value after 5.5 months High consumption days did not differ among groups, nor did anxiety level

1=2

94

2 Psychosocial Treatment for Alcohol Dependence Table 2.11b. Treatment compared with no treatment, comparison with patients on the waiting list. Study

Population

PS1

Treatment

Duration

Alden [4] 1988

N=144 67 women 77 men

1

1. Self-supervised behavior 2. Alcohol counseling 3. Waiting list n=54 for 12 weeks, thereafter rand. 1 or 2

12 w

Barber [14] 1995

N=23 partners 22 wives, 1 husband

2

1. Individual treatment 4–5 w 2. Group 4–5 w 3. Waiting list

5–6 sessions 4 months

Cadogan [28] 1973

N=40 5 women

2

1. Marital therapy 3–6 months 2. Waiting list

3–6 months

Eriksen [51] 1986

N=17 2 women

2

1. IC 7 w + self registered alcohol consumption 3 months 2. Waiting list 4 w + self-reg., thereafter inpatient care + self-reg. 3 months

1. 7 w IC 2. 4 w WL + IC

Harris [65] 1990

N=34 17 women

1

1. Self-supervised behavior: bibliotherapy 2. Self-supervised behavior: therapist-managed treatment 3. Waiting list, with self-regulation of alcohol consumption 4. Waiting list

10 sessions 10 w OC

Miller [116] 1993

N=42 24 men 18 women Problemdrinkers

1

Therapist style feedback on alcohol habit inventory 1. Confrontative = 14 2. Client-centered = 14 3. Waiting list = 14

1 session

1)



95

Followup


Outcome

Effect

12 and 24 months, 88% 127/144 1. 53/47 2. 52/46

21

After 12 w those who had been on a waiting list had poorer results than those who had been treated during that time. Otherwise no differences no drinking behavior

1=2>3

12 w

21

Patient seeks treatment/modifies consumption significantly more often in group 1 and 2 compared to 3 10/16 vs. 0/7

1=2>3

6 months after discharge

18

Sober/moderate consumption 1. 9/4 of 20 2. 2/5 of 20

1>2

3 months after completed inpatient care

18

No difference sobriety/consumption, well-being, sleep

1=2

15 months

21

Improved at 15 months (complete sobriety + controlled drinking + reduced drinking) 1 2 3 4 7 (78%) 5 (63%) 4 (50%) 5 (55%)

1=2>3=4

12 months, 83%

26

Alcohol consumption at 7 w (WL-group not yet treated): Group: 1+2 (IC) 3 (IC) Days/w 3.7 (2.7) 5.8 (2.1) SEC/w 18.9 (26.9) 35.5 (37.2)

1=2>3

Of those receiving directive (confrontative) feedback no differences versus the patients view, but the more confrontation the more increase in abuse

96

2 Psychosocial Treatment for Alcohol Dependence Table 2.12a. Motivation-enhancing treatment, motivational interviewing. Study

Population

PS1

Treatment

Duration

Bien [18] 1993

N=32 30 men 2 women

2

1. Standard treatment (12-step ground treatment in outpatient care) 2. 2 hours assessment + 1 motivational interview 1 hour + standard treatment

2 sessions (+ standard) treatment

Brown [24] 1993

N=28 21 men 7 women

2

1. Standard treatment (12-step inpatient care) 2. 2 hours assessment + 1 motivational interview 1 hour + 1


3

1. Somatic hospital treatment 2. Motivational interview during hospital stay + 1


Kuchipudi [88] N=114 1990 All men

1)



97

Followup


Outcome

Effect

3, 6 months

26

ES alcohol consumption (global measurement): 3 months 0.72 6 months 0.14 Significant effect at 3 months, not at 6 months

2>1

3 months

24

Improved at 3 months (sober or controlled drinking) 1 2 64% 29% Not improved 36% 71%

2>1

16 w, 89% followup

19

Drinking behavior at 16 weeks 1 2 Improved 20/55 21/59 Not improved 35/55 38/59

1=2

98

2 Psychosocial Treatment for Alcohol Dependence Table 2.12b. Motivation enhancing treatment, brief, CBT-oriented counseling. Study

Population

Sanchez-Craig N=90 [151] 52 men 1989 38 women


PS1

Treatment

Duration

1

1. Brief counseling + brochure 2 pages 2. Brief counseling + manual 40 pages 3. Therapist + manual 40 pages

1. 3 sessions 2. 3 sessions 3. 6 sessions

Repeat of S–C 89: 1. Brief counseling + brochure 2 pages 2. Brief counseling + manual 40 pages 3. Therapist + manual 40 pages


1

3–6 w

3–6 w

Sannibale [154] N=96 1988 All men

1

1. Grouptreatment/ind standard 2. Group/ind. cognitive therapy 3. Mini-intervention 1 conversation

7w

Miller [116] 1993

1

Therapist style feedback on alcohol habit inventory 1. Confrontative 2. Client-centered 3. Waiting list

1 session

Swenson [170] N=351 1981 All men

2

1. 1 session 30 minutes + home task 2. 4 sessions (32 hours) 3. 6 sessions (15 hours)

1, 4 and 6 sessions, respectively

Reynolds [145] N=78 1995 Pregnant women

1

1. 10 minutes counseling + self-help manual 2. Standard treatment in maternal health care

10 minutes + manual

1)




99

Followup


Outcome

Effect

3 months, (84%) 6 months, (80%) 12 months, (71%)

23

Days with heavy drinking: men 1 2 3 Admission 43 38 50 12 months 34 23 28

1=2=3

Days with heavy drinking: women 1 2 3 Admission 44 40 42 12 months 8 9 13 3 months, (83%) 6 months, (77%) 12 months, (72%)

23

Days with moderate drinking: men 1 2 3 3 months 24 33 53 12 months 10 38 47 Days with moderate drinking: women 1 2 3 3 months 77 75 50 12 months 69 75 60

15 months N=80, (83%)

20

No difference treatment groups

Women have better outcome than men

1=2=3 Women have better outcome than men

1=2=3

NB frequent followup 12 months, (83%)

26

Alcohol consumption at 7 w (WL-group not yet treated Group: 1+2 (SD) 3 (SD) Days/w 3.7 (2.7) 5.8 (2.1) SEC/w 18.9 (26.9) 35.5 (37.2)

1=2>3

Of those given directive (confrontative) feedback no differences versus the patients view, but the more confrontation the more increase in abuse 6 months, (73%) 12 months, (67%) 18 months, (62%)

16

No differences in alcohol consumption or in social problems at followup

1=2=3

2 months, (92%)

17

Complete sobriety at 2 months 1. 88% 2. 69%

1>2

100

2 Psychosocial Treatment for Alcohol Dependence Table 2.12c. Motivation enhancing treatment, primary care studies. Study

Population

PS1

Treatment

Duration

Heather [66] 1987

N=104 78 men 26 women

1

1. Self-supervised behavior 2. Simple counseling 3. No treatment

2 visits in primary care

Heather [67] 1990


1

1. 8 self-help manual, 100 pages 2. 1 + offer of telephone support 3. 1 + offer of telephone counseling 4. Simple brochure, 2 pages (control group)

Manual + telephone contact

1)



101

Followup


Outcome

Effect

6 months

19

Alcohol consumption in units (mean value + SD) 1 2 3 Baseline 170.3 (88.6) 178.0 (96.1) 231.7 (156.6) 6 months 136.8 (84.7) 147.5 (123.2) 195.2 (144.6)

1=2=3

6 months

17

Alcohol consumption at 6 months (M + SD) 1 2 3 4 46.1 (46.7) 47.1 (48.7) 50.1 (46.5) 63.3 (54.5)

1=2=3>4

102

2 Psychosocial Treatment for Alcohol Dependence Table 2.12d. Motivation enhancing treatment, self-help manual, bibliotherapy. Study

Population

PS1

Treatment

Duration

Harris [65] 1990

N=34 17 women

1

1. Self-supervised behavior: bibliotherapy 2. Self-supervised behavior: therapist-managed treatment 3. Waiting list, with self-registration of alcohol consumption 4. Waiting list

10 sessions 10 w OC

Miller [111] 1980


1

1. Bibliotherapy 2. Behavioral therapy, self-control 3. 2 + relaxation training + social skills training 4. 2 + CBT broad spectrum

2–4: 6 w + 12 w

Miller [112] 1981

N=31 23 men 8 women

1

1. Behavioral self-control training: bibliotherapy 2. Behavioral self-control training: therapist-managed treatment

1. 1 session + 3 telephone calls 2. 10 sessions, 10 w

1



Repeat of S–C 89: 1. Brief counseling + brochure 2 pages 2. Brief counseling + manual 40 pages 3. Therapist + manual 40 pages


1. Brief counseling + brochure 2 pages 2. Brief counseling + manual 30 pages with practical advice how to reduce drinking 3. Brief counseling + pamphlet with general alcohol information

1 visit



Spivak [167] 1994

1)

N=140 99 men

1

1


3–6 w

3–6 w


103

Followup


Outcome

Effect

15 months

21

Improved at 15 months (complete sobriety + controlled drinking + reduced drinking) 1 2 3 4 7 (78%) 5 (63%) 4 (50%) 5 (55%)

1=2>3=4

8 months assessment

21

Drinking pattern 6 and 12 months, share of improved: 1. 60% 60% 2. 73% 46% 3. 40% 60% 4. 80% 70%

1=2=3=4

3 months

20

Alcohol consumption in standard units 1 2 Baseline 48 57 3 months 16 24

1=2

No statistically significant differences 3 months, (84%) 6 months, (80%) 12 months, (71%)

23

Days with heavy drinking: men 1 2 3 Admission 43 38 50 12 months 34 23 28 Days with heavy drinking: women 1 2 3 Admission 44 40 42 12 months 8 9 13

3 months, (83%) 6 months, (77%) 12 months, (72%)

23


3 months, ( 78%) 12 months, (75%)

22

Reduction (%) of heavy drinking days 12 months Men Women 1. 59 82 2. 60 77 3. 29 19

1=2=3 Women had better outcome than men

1=2=3 Women had better outcome than men

1=2>3

104

2 Psychosocial Treatment for Alcohol Dependence Table 2.12e. Motivation enhancing treatment, motivation enhancing treatment. Study

Population

PS1

Treatment

Duration

Project MATCH [143] 1997

OC directly: N=952 685 men 267 women

2

1. 12-step (12 sessions) 2. CBT (12 sessions) 3. Motiv (4 sessions)

1, 2=12 sessions 3=4 sessions

1

1. Motivation enhancing therapy 2. Cognitive behavioral therapy, self-control training

1. 3–4 sessions 2. 9 sessions

IC before OC: N=774 619 men 155 women Robertson [147] N=37 1986 30 men 7 women

10 w OC 1)



105

Followup


Outcome

Effect

15 months after treatment start (90%)

27

Followup 12 months after completion of treatment. Percentage sober (month 4–15) 3. 15% = 2. 15% 2

6 w, 6, 12, 24 months

17

Complete sobriety 1 6 months 62.5 12 months 37.5 24 months 5.0

2 33.3 11.1 0

1 year

23

Number of drinking days of 90 1 2 3 Baseline 45.1 59.2 48.2 12 months 12.1 8.3 10.4

4 42.6 7.9

1 month 76.5% 73.3%

12 months: 1=2=3

1=2=3=4

6 months, 87% followup

17

Complete sobriety 1. 2.

6 months 50% 42.1%

1=2

Course during 6 months of aftercare. Total followup 86 (90%)

23

No clear difference between the treatments 1=2 Interaction mental disorder-method: Personality disorder: cognitive therapy > interactional therapy. No personality disorder: interactional therapy > cognitive therapy. Cognitive dysfunction: interactional therapy > cognitive therapy

2 years

18

Correctly matched patients significantly better outcome type I-IT, and type II-CS, respectively No total differences between treatments

1=2

8 months assessment

21

Drinking pattern 6 and 12 months, % improved: 1. 60% 60% 2. 73% 46% 3. 40% 60% 4. 80% 70%

1=2=3=4


108


Population

PS1

Treatment

Duration

Monti [119] 1990

N=69 All men

3

1. CBT/social training 2. 3 communication training + family participation 3. 3 communication training + managing emotional reactions

12 hours 4w IC

Nelson [125] 1982/83

N=33 All men

3

1. Self-assertion training – role play 2. Self-assertion training – demonstration

6 sessions 2w IC

O’Farrell [129] 1993

N=59 Couples with alcoholic husband

2

1. Behavioral marital therapy + relapse prevention 2. Behavioral marital therapy only

5 months BMT± 15 sessions RP (4 months)



2

1. 12-step (12 sessions) 2. CBT (12 sessions) 3. Motivation (4 sessions)

1, 2=12 sessions 3=4 sessions

IC before OC: N=774 619 men 155 women Sandahl [153] 1998


2

1. Dynamic group therapy 3. CBT therapy in group

4–5 months 15 sessions

Sjöberg [159] 1985

N=32 26 men

2

1. Dynamic therapy 2. CBT

5 sessions 6w

Skutle [160] 1987

N=43 34 men 9 women

1

1. 8 bibliotherapy (behavioral self control training) 2. 5 therapist-managed behavioral self control training 3. 2 skills training 4. comb 2 + 3

1. 2 sessions 2. 6 sessions 3. 6 sessions 4. 8 sessions 6–8 w OC

2

1. Dynamic treatment 2. Multimodal behavioral therapy

1 or 2 years random in both treatments

Öjehagen [182] N=72 1992 60 men 12 women

1)



109

Followup


Outcome

Effect

6 months, 77%

21

6 months: 1 2 3 % complete sobriety days: 90 91 85 Drinks/drinking day: 7.35 9.61 18.40

1=2>3

2 months, 82%

17

Complete sobriety 2 months 1 + 2 3 77.8% 55.6% Not statistically significant

1=2

12 months

24

% sober days 6 months 12 months

1>2

15 months after start of treatment (90%)

27

Followup 12 months after completion of treatment % sober (month 4–15) 3. 15% = 2. 15% 2>3

6 months

18

Time drinking alcohol: 14% vs. 79% Unemployed: 5% vs. 62% Away from home: 16% vs. 36% Institutional treatment: 2% vs. 27%

1>2

3 months

16

Alcohol consumption (ounces alc/day) 1 2 Baseline 4.67 3.56 Followup 0.85 3.32 Difference –3.83 (±5.92) –0.24 (±2.38)

1>2

12 months, 67.2% 24 months, 78.2%

26

Alcohol consumption (SEC/week) 1 2 3 Baseline 50.2 55.4 50.7 6 months 6.6 8.1 19.8 24 months 12.0 8.5 15.3

1=2=3=4

5 months

18

Days with alcohol consumption: 3 months 1.4/30 2.26/30

1>2

6 months, (84.0%) 12 months, (76.4%)

24

Alcohol consumption (drinks per week) median + SD at 12 months 1 2 35.59 (22.4) 46.67 (22.8)

1>2

4 57.6 9.5 14.8

112

2 Psychosocial Treatment for Alcohol Dependence Table 2.13c. CBT-based studies, self-control training Study

Population

PS1

Treatment

Duration

Baker [13] 1975

N=40 All men

2

1. 2. 3. 4.

5–6 h

Brown [23] 1980

N=60 All men

1

1. Behavioral self-control training 2. Information, lectures, film 3. No treatment

15 h 15 w

Caddy [27] 1976


2

1. Aversion treatment + behavioral self-control training 2. Behavioral self-control training 3. Aversion treatment (electric shock)

10 sessions 10 w OC

Duckert [45] 1992


1

1. Behavioral self-control training: group treatment 2. Behavioral self-control training: individual treatment

12 sessions 12 w

Foy [60] 1984

N=62 All men

2

1. Broad spectrum CBT + controlled drinking training 2. Broad spectrum CBT only

15 h 4w IC

Harris [65] 1990

N=34 17 women

1

1. Self-supervised behavior: bibliotherapy 2. Self-supervised behavior: therapist-managed treatment 3. Waiting list, with self-reporting of alcohol consumption 4. Waiting list

10 sessions 10 w OC

Heather [66] 1987


1

1. Self-supervised behavior 2. Simple counseling vs. 3. No treatment

2 visits in primary care

1)

Stand. treatment group Counseling + self-control training Counseling + video confrontation Counseling + (modeling) role play



113

Followup


Outcome

Effect

6 weeks, 6 months

18

% sober days (6 months): 1. 64.8 2. 55.1 3. 50.3 4. 47.3

1=2=3=4

12 months

17

Number of sober days of 90 (at 1-year followup) 1 2 3 Baseline 47.35 37.15 56.3 12 months 58.45 48.00 53.6

1>2>3

6, 12 months

15

% improved drinking pattern 1 2 6 months 80 60 12 months 76 65

1>2>3 3 30 50

3, 9, 15, 21 months

21

Alcohol consumption (1/year) group group individ. individ. men women men women Baseline 38.4 18.0 30.0 25.2 3 months 14.4 15.6 12.0 9.6 21 months 14.4 7.2 13.2 12.0

1=2

6, 12 months

22

Complete sobriety, days: 1 6 months 108.8 12 months 207.6 Days with >237 ml: 6 months 44.1 12 months 88.2

2>1

2 134.5 255.6 21.6 50.4

15 months

21

improved at 15 months (Complete sobriety + controlled drinking + reduced drinking) 1 2 3 4 7 (78%) 5 (63%) 4 (50%) 5 (55%)

1=2>3=4

6 months

19

Alcohol consumption in units (mean value + SD) 1 2 3 Baseline 170.3 (88.6) 178.0 (96.1) 231.7 (156.6) 6 months 136.8 (84.7) 147.5 (123.2) 195.2 (144.6)

1=2=3


114

2 Psychosocial Treatment for Alcohol Dependence Table 2.13c. (cont.) Study

Population

PS1

Treatment

Duration

Miller [109] 1978


2

1. Aversion treatment (self-admin. electric shock) 2. Behavioral self-control training 3. Controlled drinking training

10 sessions 10 w OC

Miller [111) 1980

N= 41 21 men 20 women

1

1. Bibliotherapy 2. Behavioral therapy 3. 2 + relaxation + social skills training 4. 2 + CBT broad spectrum

2–4: 6 w + 12 w

Miller [112] 1981

N=31 23 men 8 women

1

1. Behavioral self-control training: bibliotherapy 2. Behavioral self-control training: therapist-managed treatment

1. 1 session + 3 telephone calls 2. 10 sessions 10 w

Skutle [160] 1987

N=43 34 men 9 women

1

1. Bibliotherapy (behavioral self-control training) 2. Therapist-managed behavioral self-control training 3. Skills training 4. Comb 2 + 3

1. 2 sessions 2. 6 sessions 3. 6 sessions 4. 8 sessions 6–8 w OC

1)



115

Followup


Outcome

Effect

3 months 1 year

20

Alcohol consumption in SEC 1 2 3 Baseline 39 33 38 3 months 29 14 16 12 months 14 11 9 No statistically significant differences

1=2=3

8 months assessment

21

Drinking pattern 6 and 12 months, % improved: 1. 60% 60% 2. 73% 46% 3. 40% 60% 4. 80% 70%

1=2=3=4

3 months

20

Alcohol consumption in standard units 1 2 Baseline 48 57 3 months 16 24 No statistically significant differences

1=2

3, 6, 12 months, 95.5% followed up

20

Alcohol consumption in standard drinks 1 2 3 4 Baseline 32 33 30 46 6 months 17 11 13 8 12 months 14 13 11 14

1=2=3=4

116

2 Psychosocial Treatment for Alcohol Dependence Table 2.13d. CBT-based studies, Cue exposure (training to refrain from drinking in usually tempting situations). Study

Population

PS1

Treatment

Duration

Drummond [44] 1994

N=35 All men

3

1. 7 cue exposure 2. 6 relaxation exercises

10 h 10 days IC

Monti [120] 1993

N=40 All men

2

1. Standard treatment 2. 1 + cue exposure + skills training

6h 2w IC

Sitharthan [158] 1997

N=47 21% women

1

1. Cue exposure 2. CBT

6 sessions

1)


Table 2.13e. CBT-based studies, Other methods. Study

Population

PS1

Treatment

Duration

Baker [13] 1975

N=40 All men

2

1. 2. 3. 4.

5–6 h

Ormrod [136] 1991

N=36

2

1. Behavioral therapy anxiety 2. Relaxation training

1)

Standard treatment group Self-control + counseling + training Video self-control + counseling Counseling + (modeling) role play


6h 4w OC


117

Followup


Outcome

Effect

6 months

23

Time to relapse in heavy abuse (days) 1. 140 2. 90

6 months, 88%

22

Drank alcohol/High consumption 3–6 months 1. 79% 50% 2. 44% 31%

12

Followup


Outcome

Effect

6 weeks, 6 months

18


1=2=3=4

3 months, 81%

22

Behavioral therapy for anxiety led to lower anxiety levels compared with relaxation training, but no effect on alcohol consumption

1=2

Alcohol consumption (index) 340 550

1>2

118


12-step treatment.

Study

Population

PS1

Treatment

Duration

Carroll [29] 1998

N=117 73% men Alcohol and cocaine dependence

2

1. 2. 3. 4. 5.

12 w

Keso [84] 1990

N= 141 117 men 24 women

3

1. 12-step 2. Standard treatment

6w

Miller [115] 1992


2

1. 2. 3. 4.

12 sessions 1 session/w

Project MATCH [143, 144] 1997/1998


2

1. 12-step (12 sessions) 2. CBT (12 sessions) 3. Motiv. (4 sessions)

CBT + disulfiram 12-step + disulfiram Case M + disulfiram CBT 12-step

12-step without Antabuse 12-step + Antabuse CRA + Antabuse CRA without Antabuse

IC before OC N=774 619 men 155 women 1)


1, 2=12 sessions 3=4 sessions 3 months


119

Followup


Outcome

Effect

12 w = at completion of treatment

27

Positive effect from disulfiram on abstinence from cocaine and alcohol Active therapies CBT and 12-step better than support by case management

1/4, 2/5 >3 1=4= 2=5

12 months after completion of treatment Every second month (6 times) 77% followup at 12 months

25

Sober days 8–12 months: 1. 26.3% vs. 2. 9.8% % sober during entire followup period: 1. 14% vs. 2. 1.9% Drop-out rate: 1. 7.9% vs. 2. 23.6%

1>2

12 months, 67.2% 24 months, 78.2%

26

Alcohol consumption (drinks/week) 1 2 3 Baseline 50.2 55.4 50.7 6 months 6.6 8.1 19.8 24 months 12.0 8.5 15.3

1=2=3=4

15 months after start of treatment, (90%)

27

OC only: 36 months after completion of treatment

4 57.6 9.5 14.8

Followup 12 months after completion of treatment % sober (month 4–15) 1. 24% > 3. 15% = 2. 15% (OC) No difference IC

1 year: OC 1>2=3

Followup 36 months after completion of treatment: % sober (month 37–39) (OC) 1. 36% > 2. 24% = 3. 27%

3 years: OC 1>2=3

120

2 Psychosocial Treatment for Alcohol Dependence Table 2.15a. Studies aimed at underlying factors of abuse. Dynamically oriented therapies. Study

Population

PS1

Treatment

Duration

Olson [134] 1981


2

1. Environmental + TA therapy 2. Environmental therapy + behavioral therapy 3. Environmental therapy + TA + behavioral therapy 4. Environmental therapy

30 days

Sandahl [153] 1998


2

1. Dynamic group therapy 3. CBT in group

4–5 months 15 sessions

Sjöberg [159] 1985

N=32 26 men 6 women

2

1. Dynamic therapy 2. CBT

5 sessions 6w

2




1)



121

Followup


Outcome

Effect

113 interviewed 4 years (82%)

20

Sober 0–6 months/ 6 months–1.5 years/3.5–4 years 1. 16/26=62% / 8/26=31% / 2. 19/22=86% / 12/22=65% / 3. 28/34=82% / 22/34=65% / 4. 20/31=65% / 16/31=52% /

2>4>3>1 12/26=46% 16/22=73% 24/34=71% 21/31=68%

1 year after completed treatment 1. 23/25: 92% 2. 21/24: 87.5%

19

Past 6 months sober/no intoxication drinking 1. 13/23 = 57% 2. 6/21 = 28% Sober days last 3 months vs 3 months before; 1>2

1>2

At completion of treatment (100%)

18

No difference in relapse

1=2

1 year and 2 years, respectively, after completion of treatment Followed up 1. 29/36 = 81% 2. 34/36 = 94%

24

No difference between treatment option 1 or 2 or between 1 or 2 years of treatment. Matching effect: 1. Dynamic therapy: patient with better mental status better outcome and those poorer mental status poorer results 2. Cognitive therapy: results less associated with mental status

1=2

122

2 Psychosocial Treatment for Alcohol Dependence Table 2.15b. Studies aimed at underlying factors of abuse. Interactional therapies. Study

Population

PS1

Treatment

Duration

Cooney [36] 1991


2

1. Interactional therapy 2. Cognitive behavioral therapy

6 months + 2 sessions until 12 months (total 20 sessions)

Ito [77] 1988

N=39 All men

2

1. Hospital care 28 days + relapse prevention 2. Hospital care 28 days + interactional therapy

8 sessions 4w IC

Kadden [80] 1989


2


6 months

Litt [92] 1992

N=79 All men

2

1. Skills training 2. Interactional therapy

26 sessions 6 months OC

1)



123

Followup


Outcome

Effect

0.5 and 1.5 years after completion of treatment (1 year and 2 years after initiation of aftercare)

22

No difference between treatments Interaction: personality disorder, cognitive dysfunction – method Matching effect, see matching report

1=2

6 months, 87% followup

17

Complete sobriety 1 month / 6 months 1. 76.5% / 50% 2. 73.3% / 42.1%

1=2

6 months = at completion of treatment Total followup 86 (90%)

23

No clear difference between treatments Interaction mental disorder – method: Personality disorder: cogn therapy > interact. therapy. No personality disorder: interact. therapy > cogn. therapy. Cogn. dysfunction: interact. therapy > cogn. therapy

1=2

2 years

18

No differences in total between the treatments

1=2

124

2 Psychosocial Treatment for Alcohol Dependence Table 2.15c. Studies aimed at underlying factors of abuse. Others: Psychotherapy. Study

Population

PS1

Treatment

Duration

Bruun [25] 1962

N=303 All men

2

1. Psychotherapy unspecified A-clinic = 203 2. Antabuse M-clinic = 100 3. Normal group = 402

1 = 32 sessions 2 = 10 sessions

Zimberg [180] 1974

N=107 All men

3

1. Psychotherapy ind./group, counseling mixed = 58 2. Medication/antabuse/ ind. support = 49 3. Self-selected daycare from group = 6

12 months

1)



125

Followup


Outcome

Effect

2–3 years after inclusion 1 = 174 (86%) 2 = 86 (86%) 3 = 349 (87%)

16

Sober or moderate consumption 1. 38/174 (22%), improved 47/174=27% 2. 16/86 (19%), improved 23/86=27%

1=2

1 year after initiation of treatment 1 + 2 = 78/107 = 73% Total: 83/113 = 73%

18

Sober 23 w or more during past year 1. 9/420=21%, minimal consumption/no problems 17=40% 2. 10/36=28%, minimal consumption/no problems 16=44% (3. 1/5=20%)

1=2

126


Standard treatment.

Study

Population

PS1

Treatment

Duration

Allsop [5] 1997

N=60 All men

3

1. Relapse prevention: role play, skills training 2. Relapse prevention: role play, self confidence training 3. Standard treatment: abstinence treatment, information, group discussion

8 hours 2w OC

Azrin [9] 1976

N=18 All men

2

1. CRA, including Antabuse 2. Standard treatment: abstinence treatment, information, group discussion

30 h IC

Azrin [10] 1982

N=43 36 men 7 women

2

1. CRA + Antabuse supervision program 2. Antabuse supervision program 3. Standard treatment: recommendation antabuse, family member support, advice and support

6h 6w OC

Baker [13] 1975

N=40 All men

2

1. Standard treatment group 2. Self-control + counseling + training 3. Video self confrontation + counseling 4. Counseling + (modeling) role play

5–6 h

Carroll [29] 1998

N=117 85 men 32 women Alcoholand cocaine dependence

2

1. 2. 3. 4. 5.

12 w

Eriksen [52] 1986

N=24 Inpatient care

3

1. Advice/support as usual 2. Advice/support + social skills training

8w 8 sessions

Gilbert [62] 1988

N=96 All men

2

1. OP as usual after IP treatment 2. 1 + telephone reminder 2-3 days before visit 3. OP by house call

Active followup (2, 3) 6 months

1)

CBT + disulfiram 12-step + disulfiram Case M + disulfiram CBT 12-step



127

Followup


Outcome

Effect

6 months 1 year

23

Complete sobriety:

Moderate consumption, number of weeks 6 months 12 months 6 months 12 months 1. 44.4% 20% 20 14.1 2. 5% 5% 15 11.5 3. 5% 0 9.4 12.3

6 months: 1>2>3

1>2

12 months: 1=2=3

6 months 24 months (incomplete data)

22

6 months: 1 compared with 2 Time drinking alcohol: 2% vs. 55% Unemployed: 20% vs. 56% Away from home: 7% vs. 67% Institutional treatment: 0% vs. 45%

6 months

24

Outcome 6 months: Days Amount/ Days with drinking occasion Antabuse 1. 0.9 0.7 oz 24.8 2. 7.9 1.7 oz 19.3 3. 16.4 4.1 oz 0

6 weeks 6 months

18


1=2=3=4

12 w = at completion of treatment

27

Positive effect of disulfiram on abstinence from cocaine and alcohol. Active therapies CBT and 12-step better than support by case management

1/4, 2/5 >3 1=4= 2=5

1 year 23/24

20

Group: 1 Alcohol cons. 23 cl/w Sober days 32% Days working 45%

1< 2

Every 3rd month until 1 year

22

Active followup increased attendance OP treatment, but did not result in better outcome concerning alcohol consumption

1>2>3 Unem- Away ployed from home 2.2% 0 3.2% 0 10.9% 4.4%

2 14.2 cl/w 77% 97%

1=2=3


128


(cont.)

Study

Population

PS1

Treatment

Duration

Hunt [74] 1973

N=16 Men

2

1. CRA 2. Standard treatment: 12-step

50 hours IC

Jones [79] 1982


2

1. IP (standard 12-step treatment) 2. 1 + discussion group (emotional factors involved) 3. 1 + social skills training 6 sessions twice/w

28 days

Keso [84] 1990


3

1. 12-step 2. Standard treatment

6w IC

Monti [119] 1993

N=40 All men

2

1. Standard treatment 2. 1 + cue exposure + skills training

6 hours 2w IC

Nelson [125] 1982/83

N=33 All men

3

1. Self assertion training – role play 2. Self assertion training – demonstration

6 sessions 2w IC

Ogborne [131] 1979

N=40 Homeless men

3

1. Counseling 2. No treatment

Maximum 6 months

Pittman [139] 1972


2

1. IP + OP medication, support, 3–6 w 2. IP, standard detoxification, 7–10 days

1. Max 6 w 2. Max 10 days

Pomerleau [140] 1978


1

1. Traditional support, confrontation AA 9 w; aim sobriety 2. Behavioral therapy 5.5 w, direction control consumption

approximately 9 months 19 sessions

1)



129

Followup


Outcome

Effect

6 months

18

Time drinking alcohol: 14% vs. 79% Unemployed: 5% vs 62% Away from home: 16% vs 36% Institutional treatment: 2% vs 27%

1>2

11–14 months after discharge 45% followed up

18

Alcohol consumption during the followup year 2, 3 >1 (2=3)

1< 2=3

12 months after completion of treatment every second month (6 times) 77% followup at 12 months

25

Share of sober days 8–12 months: 1. 26.3% vs 2. 9.8% Share of sober the entire followup period: 1. 14% vs 2. 1.9% Dropout rate: 1. 7.9% vs 2. 23.6%

1>2

6 months, 88%

22

Drank alcohol / High consumption 3–6 months: 1. 79% 50% 2. 44% 31%

12, 3

1>2, 3

132

2 Psychosocial Treatment for Alcohol Dependence Table 2.17a. Marital therapy and interventions directed at family members. Marital therapy. Study

Population

PS1

Treatment

Duration

Bowers [21] 1990

N=16 14 men Alcohol problems

2

1. CBT marital therapy in group hours 2. Standard individual therapy, info, support

14 w

Cadogan [28] 1973

N=40 2 Husband alcohol problems

1. Marital therapy 3–6 months 2. Waiting list

3–6 months

Longabaugh [94] 1994


2

1. Cognitive behavioral therapy patient only 2. Relat. increasing cogn. (family members participate 4–8 sessions)

4–6 months + some boostersessions until 12 months = 20 sessions total



2

1. CBT including 8 rel. increasing sessions with family members 2. CBT including 4 family member sessions + occupational therapy 3. CBT therapy group (patient only)

6 months 20 sessions, of which 2 are given 6–12 months after initiation of treatment

McCrady [100] 1979

N=33 20 men

2

1. IP + OP ind. + marital 2. OP ind. + marital 3. IP + OP patient only

–

McKay, Longabaugh [102] 1993


1. CBT individual treatment 2. CBT including marital therapy (partner participate 4–8 sessions)

4 months 20 sessions once/w completion of treatment

McCrady [101] 1986

N=45

1. Marital therapy focus alcohol + the relationship 2. Marital therapy focus alcohol 3. Family members participate, focus patient

16 w 15 sessions

1)

2



133

Followup


Outcome

Effect

6, 12 months 28/32 (88%) 1. 15/16 2. 13/16

20

Average number of drinks/w: 6 months: 1>2, 12 months: 1>2 Sobriety: no difference. When consumption: 1 drank less than 2. Satisfaction with the relationship 1>2

1>2

6 months after discharge

18

Sober/moderate consumption 1. 9 of 20 /4 of 20 2. 2 of 20 /5 of 20

1>2

6 months after completion of treatment (18 months after initiation of treatment)

22

No difference between treatments Results not stated in relation to treatment. Matching results: 1>2 in antisocial personality disorder – method

1=2

6 months after completion of treatment Subsample 188 165/188 = 88% 1=58, 2=50 3=57

23

Abstinent % days past 3 months, 1 year after completion of treatment 1. 50/58 = 86% 2. 47/57 = 83% 3. 45/50 = 90% ns Matching results in relation to network characteristics

1=2=3

6–8 w 6–8 months

21

All groups reduced relationship problems, anxiety, depression, deterioration due to alcohol. Only 1 significant reduction in consumption, but others also reduction

1=2=3

6 months after initiation of, treatment ie 2 months after

22

% days abstinence 1–3 months, 4–6 months: 1=2, role functioning: 2>1 Matching results: 1. ind. therapy >2. marital therapy more dependent. Marital therapy tends to give better family function than individual therapy for independent patients (according to partner)

1=2

6 months after treatment 92.3% patient 89.3% family memb. No difference 1–3

25

Sobriety, abuse days 1=2=3 1>2. reduction of consumption earlier, relapse later, satisfaction with the relationship 1>3. still in treatment, maintained satisfaction with relationship

1=2=3


134


Population

PS1

Treatment

Duration

Monti [119] 1990

N=69 All men

3

1. CBT/social training 2. 3 communication training + family participation 3. 3 communication training + CBT management of emotional reactions

12 hours 4w IC


N=34 Husband alcohol problems

2

1. Behavioral marital therapy (including Antabuse contract) + individual counseling 2. Interactional marital therapy + individual counseling 3. Individual counseling

8 sessions 10 w


N=34 Husband alcohol problems

2

1. Behavioral marital therapy (including Antabuse contract) + individual counseling 2. Interactional marital therapy + individual counseling 3. Individual counseling

8 sessions 10 w



1. After marital therapy addition of relapse prevention couple 2. 0 added relapse prevention sessions

Initial marital therapy = 5–6 months + relapse prevention = 12 months

2

1. After marital therapy addition relapse prevention couple 2. 0 added relapse prevention sessions

Initial marital therapy = 5–6 months + relapse prevention = 12 months

2

1. Systemic marital treatment 8 sessions 2. One couple conversation

Max. 2 months

Behavioral therapy couple, thereafter with or without addition of relapse prevention O’Farrell [130] 1998

N=59 Husband alcohol problems Behavioral therapy couple, thereafter with or without addition relapse prevention

Zweben [181] 1988

1)

N=218



135

Followup


Outcome

Effect

6 months, 77%

21

6 months: % complete sobriety days: Drinks/drinking day:

12–14 w after treatment start (88%) i.e., at the end of treatment

22

Sobriety, abuse not stated, instead % no consumption + no negative consequences 1>2, 3 satisfactory relationship 1>3 relationship, communication 1>2 drinking days Tend 1>2, 3 consumption and satisfactory relationship

1=2=3

2 years after treatment

22

1>3 satisfactory relationship 1=2=3 consumption

1=2

12 months after initial marital treatment

24

% sober days 1 6 months 96.8 12 months 94.0

1>2

18, 24, 30 months after completed marital therapy, i.e., 18 months after completion of relapse prevention

23

Relapse prevention has better outcome through 6 months after relapse prevention. Patients with more severe marital and abuse problems have better outcome through 30 months than if they received marital therapy alone. All who received relapse prevention had better relationship through 30 months

1>2

12 months: dropout treatment of followup 116=47%

22

No differences abuse days or other outcome measures 1>2 satisfaction treatment (no influence results)

1=2

1 2 3 90 91 85 7.35 9.61 18.40

2 87.6 81.9

1=2>3

(1, 2>3 1>2, tend)

136

2 Psychosocial Treatment for Alcohol Dependence Table 2.17b. Marital therapy and interventions aimed at family members. Family members are involved as support in the treatment. Study

Population

PS1

Treatment

Duration

Ahles [3] 1983

N=50 Men only

2

1. Aftercare with treatment contract including family members, support, calendar 2. Standard aftercare

6 months 8 sessions

Keane [83] 1984

N=25 All men

2

1. Antabuse intake in the presence of a family member according to contract = 8 2. 1 + positive feedback = 8 3. Antabuse use no contract = 9

3 months

Mallams [98] 1982


2

1. Standard + CRA – support for participation in social club 2. Standard treatment + info about social club

6 sessions 6w

1)



137

Followup


Outcome

Effect

1 year after discharge per telephone 72% 1. n=18 2. n=18

16

Sober months 3, 6, and 12: 1>2, continuously sober until 6 months, tend 12 months: 1>2 Sober month 1–6 / 7–12 / working month 12 1. 77.8% / 38.9% / 46.7% 2. 16.7% / 11.1% / 13.3%

1>2

3 months

20

Got prescription Antabuse 3 months according to pharmacy 1 + 2: 14/16 = 88%, 3: 5/9 (56%) After 3 months use 14/16 in group 1 + 2 and 7/9 in group 3 Antabuse (ns)

1=2=3

3 months

16

Alcohol consumption per day 1 2 Baseline 4.67 3.56 Followup 0.85 3.32 Difference –3.83 (±5.92) –0.24 (±2.38)

1>2

138

2 Psychosocial Treatment for Alcohol Dependence Table 2.17c. Marital therapy and interventions aimed at family members. Intervention partners. Study

Population

PS1

Treatment

Duration

Barber [14] 1995

N=23 22 wives 1 husband

2

1. Individual treatment 4–5 w 2. Group 4–5 w 3. Waiting list

5–6 sessions 4 months

Sisson [157] 1986

N=12 Family members

2

1. CRA for partner 2. Standard treatment for family members

7–8 hours 7w OC

1)



139

Followup


Outcome

Effect

12 w

21

Patient seeks treatment/modifies consumption significantly more often group 1 and 2 compared to 3 (10/16 vs 0/7)

1=2>3

5 months

18

Days with alcohol consumption: 3 months 1. 4/30 2. 26/30

1>2

140

2 Psychosocial Treatment for Alcohol Dependence Table 2.18a. Matching studies. Matching to specific treatment methods. Study

Population

PS1

Treatment

Duration

Cooney [36] 1991


2


6 months + 2 sessions until 12 months (total of 20 sessions)

2


6 months

2

1. Coping skills (CS) 2. Interactional therapy (IT)

26 sessions 6 months OC

2


1, 2 = 12 sessions 3 = 4 sessions 3 months

Patient characteristics: mental disorder, cognitive dysfunction Kadden [80] 1989

N=96 63 men 33 women Patient characteristics: mental disorder, cognitive dysfunction

Litt [92] 1992

N=79 All men Patient characteristics: alcohol abuse type I and II

Project MATCH [143, 144] 1997

OC directly: N=952 685 men 267 women IC before OC: N=774 619 men 155 women

Patient characteristics: mental ill health, (global measurement), degree of dependence, motivation, antagonism (personal) 1)



141

Followup


Outcome

Effect

0.5 and 1.5 years after completion of treatment (1 year and 2 years after aftercare was initiated)

22

No difference between treatments Interaction: personality disorder, cognitive dysfunction – method 2>1 mental disorder 1>2 no mental disorder 1>2 cognitive dysfunction

1=2

Course during 6 months treatment Total followup 86 (90%)

23

No clear difference between treatments Interaction mental disorder – method: Personality disorder: cognitive therapy > Interactional therapy No personality disorder: Interactional therapy > cognitive therapy Cognitive dysfunction: interactional therapy > cognitive therapy

1=2

2 years

18

No differences in total between treatments Correctly matched patients significantly better outcome type I with IT, and type II with CS, respectively

1=2

15 months after initiation of treatment 1 year after completion of treatment (90%)

27

12-step > CBT at low level of mental problems 5–11 months after treatment direct OP

1 year: 1>3=2

MET > 12-step low motivation 12th month after treatment direct OP CBT > 12-step low dependence (IP-study) 12-step > CBT high dependency (IP-study) MET > CBT, 12-step: high antagonistic (OP) CBT > MET: low antagonistic (direct OP)


142


Population

PS1

Treatment

Duration



2

1. Cognitive behavioral therapy, CBT 2. 12-step 3. Motivation enhancement therapy, MET

1, 2 = 12 sessions 3 = 4 sessions 3 months

2



Patient characteristics: antagonism (personal), tolerance of the network for consumption Öjehagen [182] N=72 1992 60 men 12 women Patientcharacteristics: mental status

1)



143

Followup


Outcome

Effect

3rd year after completion of treatment past, 3 months

27

MET > CBT, 12-step high antagon. personal CBT, 12-step > MET low antagon. personal (% sober days, drinks/drinking day)

1=2=3 (OP)

12-step > MET if network tolerant alcohol consumption (% sober days, drinks/ drinking day) (mediating effect from AA-participation after treatment)

1 year and 2 years, respectively, after completion of treatment Followed up 1. 29/36 = 81% 2. 34/36 = 94%

24

No difference between treatment alternative 1 or 2 or between 1 or 2 years of treatment Matching effect: 1. Dynamic therapy: patient with better mental status better outcome and those with poorer mental status poorer outcome 2. Cognitive therapy: outcome less associated with mental status (ns)

1=2

144

2 Psychosocial Treatment for Alcohol Dependence Table 2.18b. Matching studies. Matching to treatment which involves partner. Study

Population

PS1

Treatment

Duration



2

1. Individual CBT 2. Marital therapy CBT

4–6 months + some booster sessions until 12 months = total of 20 sessions

Patient characteristics: social support, sobriety, need of social support Longabaugh [94] 1994

N=139 96 men 43 women Patient characteristics: antisocial personality disorder

2

1. Cognitive behavioral therapy patient only = 53 2. Relat increasing cogn. = 86 (family members participate 4–8 sessions)

4–6 months + some booster sessions until 12 months = 20 sessions total



2

1. CBT including 8 rel. increasing sessions with family members 2. CBT including 4 family member sessions + occupational therapy 3. CBT therapy group (patient only)

6 months 20 sessions, of which 2 until 12 months after initiation of treatment

2

1. CBT individual treatment 2. CBT including marital therapy (partner participates 4–8 sessions)

4 months 20 sessions once/w

2

1. CBT (group) not family members 2. 1 + 8 sessions relationship enhancing treatment 3. 1 + 4 sessions relationship enhancing treatment + 4 sessions occupational therapy

20 sessions 4–6 months

Patient characteristics: importance of the network to the patient, the importance of the network for sobriety McKay, Longabaugh et al. [102] 1993

Rice [146] 1993

N=51 Patient characteristics: not independent (personality) N=229 150 men 79 women Patient characteristics: age groups: 18–29, 30–49, 50+

1)



145

Followup


Outcome

Effect

Monitors patient 12 months, i.e., until end of intervention n=107 47% complete info.; 80% partial info.

24

1. CBT (ind.) = 2. relationship enhancement in good social support 1. CBT (ind.) >2. relationship enhancement in weak social support Relationship enhancement treatment poorer if patient not in need of social support

1=2


22

No difference between treatments Outcome not stated in relation to treatment 1>2 in antisocial personality disorder 1–2 no personality disorder

1=2

6 months after end of treatment Subsample 188 165/188 = 88% 1=58, 2=50 3=57

23

Matching effects in relation to varied number of family member sessions (8 or 4 sessions) 2>1 in patient whose network not supportive for sobriety or when network of less importance 1>2 patient whose network did not give support for sobriety + when network is of less importance, or when a supportive network of great importance existed

1=2=3

6 months after initiation of treatment, i.e., 2 months after end of treatment

22

% days of abstinence 1–3 months, 4–6 months, 1=2, 2>1 role functioning

1=2

3–6 months after initiation of treatment 83%

23

1. Less independent: individual therapy > marital therapy 2. Independent patient: Marital therapy tend better family function > individual therapy No differences between treatment methods Matching method – age group: 1=2=3: treatment method no significant differences 18–29 years 2>1 relationship-enhancing treatment better 30–49 years (ns) 1>3 cognitive therapy better 50+ (p2 those with less faith in own ability 1=2 good faith in own ability

6 months followup = 111, 85% 94 (72%) included in all data analyses

23

For patients who had other problems 2>1 = they stayed longer in treatment and improved more in these fields

1=2

Followup 12 months (86%) Followup 24 months (82%)

23

Improvements regardless of structure of treatment Correctly matched smaller interruptions from treatment; fewer relapses, better health

1=2

18, 24, 30 months after completed BMT, i.e., 18 months after completion of relapse prevention

23

Relapse prevention better outcome until 6 months after relapse prevention For all who received relapse prevention better relationship until 30 months For patients with more severe marital and abuse problems relapse prevention better outcome until 30 months than if they were given BMT only

1>2

2 years, 84%

20

No differences at a group level

1=2

Matching results: physical dependence1>2 no physical dependence: 13

150

2 Psychosocial Treatment for Alcohol Dependence Table 2.19a. Studies comparing the intensity and aftercare of treatment. Comparing inpatient care – outpatient care. Study

Population

PS1

Treatment

Duration

Chapman [31] 1988


2

1. IP (med./therapy/AA) 6 w 2. OP (unspecified + partner) 6 w 3. 1 confrontative conversation with partner

6w

Edwards [46] 1967

N=40

2

1. Hospital treatment IP 8.9 w 2. OP 7.7 w 1 visit/w

1. 8.9 w 2. 7.7 w

Eriksen [51] 1986

N=17

2

1. Inpatient care 7 w + self-reg. 3 months 2. Waiting list 4 w + self-reg., thereafter inpatient care + self-reg. 3 months

4w


N=174

2

1. Hospital treatment = 14.1 days (60) Day care = 14.7 days (114)

2w 1. 11 sessions 2. 15 sessions

McLachlan [104] 1982


2

1. Inpatient care treatment 4 w 2. Day care

4w

Pittman [139] 1972


2

1. IP + OP medication, conversational support, 3–6 w 2. IP, standard detoxification, 7–10 days (C)

1. Max. 6 w 2. Max. 10 days

Potamianos [141] 1986


2

1. Trad. IP + OP 2. Day care

1)

2.



151

Followup


Outcome

Effect

6, 18 months after initiation 84/113, 86% 1. 32/36 2. 23/35 3. 29/34

21

No difference at 6 months and 18 months: sobriety, moderate consumption drinks/drinking day

1=2=3

Every month through 1 year 100% followed up

22

No differences in outcome concerning drinking patterns and consequences Assessment monthly

1=2

3 months after completed inpatient care

18

No difference sobriety/consumption, well-being, sleep

1=2

Once/month 6 months

22

2. As good as 1, but at a lower cost Several measurements

1=2

4 and 12 months after completion of treatment Followup: 97/100 = 97%

21

Sober: 1. 17/48 2. 17/49 Max. 14 drinking days/year: 1. 29/48

1 year after discharge Interview 232 (93%)

14

Sober the entire followup period/minimum 7 months during followup 1. 19/163 = 12% / 47/163 (29%) 2. 3/69 = 4% / 15/69 (22%) ns More intensive treatment: tends to better outcome consumption and social variables

1=2

3, 6, 12 months 115 patients (79%) 1. 53/70 2. 62/81

20

Daily alcohol consumption (mean value 1 w before interview) 2>1 (multiple regression analysis) 1. 106 g/day 2. 89 g/day Sober 12 months: 1 = 10%, 2 = 17%: No difference other measurements Assessment 3, 6 and 12 months

2>1

1=2 2. 29/49

No difference between the treatments Two followups within 12 months


152


Population

PS1

Treatment

Duration

Smith [161] 1995

N=149 All women

3

1. Environmental therapeutic community with supportive housing the first 3 months + 12-step treatment 2. As in 1, but no supportive housing the first 3 months

3 months intensive treatment + 9 months low intensive

Sosin [165] 1995

N=418 309 men 109 women

3

1. Case management (CM) only (as aftercare after detoxification in IP) 2. CM + supportive housing 3. No aftercare

1. 3 months 2. 6 months

Walsh [177] 1991


2

1. IP: hospital 3 w, AA/w + control sobriety + work 1 year 2. Participation AA (OP) 3 times/w 1 year + control sobriety at work 3. Treatment of choice

All 1 year

Wanberg [178] N=180 1974 146 men 34 women

2

1. Inpatient care 2 w (hospital) 2. Outpatient care, 3 sessions in 2 weeks

2 w and 3 sessions/2 w respectively

Review: Outpatient care – Inpatient care Finney [56] 1996

1)

Review OP compared IP 14 studies of which 10 rand. included here

10 studies are included in this analysis: Edwards [46] 1967 Pittman [139] 1972 Wanberg [178] 1974 Mosher [122] 1975 Stein [168] 1975 Eriksen [51] 1986 McLachlan [104] 1982, Chapman [31] 1988, Chick [32] 1988, Walsh [177] 1991



153

Followup


Outcome

Effect

18 months from admission 90% followed up

22

No improvement in alcohol habits over time; no difference between the groups No differences concerning housing and work

1=2

12 months; 73.7% followup

19

Number of drinking days out of past 30: 1 2 3 Baseline 17.8 16.9 16.4 12 months 4.8 4.3 6.8

1=2>3

2 years after initiation of treatment (1, 3, 6, 12, 18, 24) Followup: 1. 63/73, 86% 2. 73/83, 88% 3. 64/71, 90%

23

Sobriety during the entire outcome year: 1>2, 3 1. 23/63 = 37% 2. 12/73 = 16% 3. 11/64 = 17% Analysis also of share of never intoxicated 1>2, 1>3, 2=3 Inpatient care outcome year: 1. 23%, 2. 63%, 3. 38% Frequent followup

1>2 1>3 2=3

3 months 1. 88, 70% 2. 40, 74%

20

No difference sobriety 1. 33% 2. 30% Social adaptation: 10 of 25 questions 1>2

Sobr: 1=2 Adap. 1>2

7 of 14 studies differences: 5 studies IP > OP (of these here: Wanberg [178] 1974, Chick [32] 1988, Walsh [177] 1991) 2 studies day care > IP Studies where IP better, OP did not have abstinence treatment, social instability not as inclusion criteria and less often randomized

154

2 Psychosocial Treatment for Alcohol Dependence Table 2.19b. Studies comparing the intensity and aftercare of treatment. Treatment duration, inpatient care. Study

Population

PS1

Treatment

Duration

Mosher [122] 1975


2

1. 9 days IP (detoxification/ advice, ind. = 105 2. 21 days IP (advice etc.) = 95

9 days 21 days

Stein [168] 1975

N=58 All men

2

1. Detoxification IP 9 days, ind. assessment aftercare 2. Detoxification + IP 30 days (eclect., extensive content)

9 days 30 days

Stinson [169] 1979


2

Four comparisons 1. IP high staff ratio + OP extensive resources 2. IP high staff ratio + OP inform less resources 3. IP low staff ratio + OP extensive resources 4. IP low staff ratio + OP inform less resources

4–6 w IP OP not stated

Walker [176] 1983

N=245 All men

2

1. 2 w 2. 7 w

2 and 7 w

Willems [179] 1973

N=69 All men

2

1. IP (hospital) brief, max 4 w 2. IP (hospital) long, 8–26 w

1. 20 days 2. 82 days

1)



155

Followup


Outcome

3 months, 91% 6 months, 82%

17

Sober 1. 2.

2, 4, 7, 10 and 13 months after admission 1. 26/29 2. 27/29

20

Control baseline data no differences Sober 7 months 13 months 1. 11/26 11/26 2. 8/27 10/27 Frequent followup

1=2

3, 6, 12, 18 months, 86%

21

Consumption level, drinking behavior only (scale) 3 and 4>1 and 2

3, 4>1, 2

3 months 35% 32%

Effect

6 months 23% 18%

1=2

No differences social function, need of care, accomplish goals Close followup

9 months

2 years after discharge, (90%)

23

No difference neuropsychological function in relation to duration of inpatient care Study (non-rand.) found that patients who participated in aftercare 1/w for 9 months were sober more often than others

1=2

Status at 12 months (%): 1 Recovered 28.9 Improved 42.1 Unchanged 28.9 Close followup

1=2 2 44.8 13.8 41.4

156

2 Psychosocial Treatment for Alcohol Dependence Table 2.19c. Studies comparing the intensity and aftercare of treatment. Duration of treatment, outpatient care. Study

Population

PS1

Treatment

Duration

Bennie [16] 1998

N=95

2

1. Home detoxification (8 visits) 2. Mini-intervention 1 visit, no medication, advice

1. 5 days 2. once + once after 4 w

Chapman [31] 1988


2

1. IP (medication/therapy/AA) 6 w 2. OP (unspecified + partner) 6 w 3. 1 confrontative conversation with partner

6w

Chick [32] 1988

N=153

2

1. Extended advice/support 1988 (IP/OP) 2. One session advice/support 3. 5 minute advice

2–4 w

Edwards [47] 1977

N=100 All men (married)

2

1. More extensive treatment 2. One counseling interview

1. 12 months

Orford [135] 1976

N=100 All men (married)

2

1. More extensive treatment 2. One counseling interview (Followup partner once/month first year

1. 12 months

Sannibale [154] N=96 1988 All men

1

1. Group treatment/indiv. standard 2. Group/ind. cognitive therapy 3. Mini-intervention 1 conversation

7w

Zweben [181] 1988

2

1. Systemic marital therapy (8 sessions) Max. 2. One couple conversation 2 months

1)

N=218 Couples



157

Followup


Outcome

Effect

6 months 76/95 80% (1=40; 2=36)

22

1. (Detoxification house call) sober twice as long (number of weeks) as 2. mini-interv. 1. 16.3±6.8 2. 9.6±8.1 p2

6, 18 months after initiation, 84/113, 86% 1. 32/36 2. 23/35 3. 29/34

21

No difference at 6 months and 18 months: sobriety, moderate consumption, drinks/drinking day

1=2=3

2 years Followup family member every third month

25

Sobriety: no difference Increased advice less negative consequences of drinking

Sobriety: 1=2=3 Alcohol related problems: 1>2=3

1 year (94%) Followup every month through partner

21

No differences in outcome concerning drinking pattern and consequences

1=2

2 years, 84%

20

No differences at a group level Matching results: Physical dependence 1>2 No physical dependence: 12 satisfaction treatment (no influence outcome) close followup, group 2 = 5 followup

1=2

158

2 Psychosocial Treatment for Alcohol Dependence Table 2.19d. Studies comparing the intensity and aftercare of treatment. Different number of hours in treatment. Study

Population

PS1

Treatment

Duration

Kamara [81] 1998


3

1. Standard OP 3 months 2. Standard OP 6 months

3 and 6 months respectively

Maisto [97] 1985

N=48 All men

2

1. Time-limited treatment Max 9 months + personal followup 2. Time-limited treatment + data followup 3. Unlimited treatment + personal followup 4. Unlimited treatment + data followup


N=59 2 Couples, husband alcohol problems

1. After marital therapy addition relapse prevention couple 2. 0 additional relapse prevention sessions

Initial treatment = 5–6 months + relapse prevention = 12 months


N=59 2 Couples, husband alcohol problems

1. After marital therapy addition of relapse prevention couple 2. 0 addition relapse prevention sessions

Initial treatment = 5–6 months + relapse prevention = 12 months

1. Supportive measures, Antabuse, 100 hours 2. Antabuse + medication prescription once/month 3. Somatic followup, no medication once/month

1 year

Behavioral therapy couple, thereafter with or without addition of relapse prevention Powell [142]

1)

N=174

2



159

Followup


Outcome

Effect

3, 6 months after IP

19

2 somewhat better than 1: more often medical, visits, homemaker, fewer arrests

1=2

Once/months until 1.5 year 42/48, 87.5%

19

1. In treatment several weeks, but not more times (ns) Followup once/month of patient and family member 1. 35.3 w 2. 22.0

1=2=3=4

Followup once/month of patient and family member 12 months

24

% sober days 1 6 months 96.8 12 months 94.0

2 87.6 81.9

1>2

18, 24, 30 months after completed BMT, i.e., 18 months after completion of relapse prevention

23

Relapse prevention better outcome until 6 months after relapse prevention. For all who received relapse prevention better relationship until 30 months

1>2

For patients with more severe marital and abuse problems better outcome until 30 months than if they were given marital therapy only

6 months, 1 year after completion of detoxification 148/174 = 85%

Share drinking since 6 months/mean value of severity of drinking 1. 39% of 49 / 9.5±7.6 2. 39% of 49 / 10.5±8.2 3. 37% of 50 / 9.5±7.6


160

2 Psychosocial Treatment for Alcohol Dependence Table 2.19d. (cont.) Study

Population

PS1

Treatment

Duration

Project MATCH [143, 144] 1997, 1998

OP directly: N=952 685 men 267 women

2


1, 2. 12 sessions 3. 4 sessions 3 months

2



IP before OP: N=774 619 men 155 women Öjehagen [182] N=72 1992 60 men 12 women

1)



161

Followup


Outcome

Effect

15 months after initiation of treatment (90%)

27

Followup 12 months after completion of treatment share of sober (month 4–15) 3. 15% = 2. 15% 2

3 months, 12 months 101 = 70%

18

Patients with more severe marital and abuse problems had better outcome through 30 months than if they were given BMT alone

No differences followup 1–4 consumption Association accomplishment-treatment and accomplishment-followup Difficult to reach patient for intensive followup, few (38%) kept a diary

1=2=3=4

166


Treatment of mentally disturbed abusers.

Study

Population

PS1

Treatment

Duration

Burnam [26] 1995

N=276 Homeless abusers with severe mental disorder

3

1. Housing including coordinated intervention for abuse, mental disorder, n=67 2. As in 1 but no housing support, more case management (no coordinated treatment) = 144 3. No specific intervention, but free access to municipal service n=65

3 months intensive + 3 months further treatment when needed

Cooney [36] 1991


2


6 months + 2 sessions until 12 months (total 20 sessions) 3 years

mental disorder Drake, McHugo [43] 1998

N=223 2 Schizophrenia, bipolar disorder, schizoaffective disorder

1. Integrated treatment in special teams (assertive community treatment) 2. Standard case management

Fals-Stewart [53] 1992

N=60 Co-morbidity: compulsive syndrome

3

1. Treatment compulsion + abuse = 19 1. 3 times/w 2. Treatment abuse + relaxation = 18 6w 3. Treatment of abuse only = 20

Fisher [57] 1996

N=44 Co-morbid Personality disorder (Cluster B and C)

3

1. IP (CBT vs AA vs standard treatment) = 19 2. OP (CBT vs AA vs standard) treatment = 19

12 w, 3 times/w

Jerrell [78] 1995

N=132

2

1. CBT 2. Intensive case management (including education drugs) 3. AA groups within teams

18 months

Lehman [90] 1993

N=54 2 Severely mentally disturbed (schiz. affective disorder)

1. Traditional psychiatric treatment (no treatment abuse) 2. 1 + intensive case management (= few representatives/pat.) including group treatment with sobriety as a goal

1 year

1)



167

Followup


Outcome

Effect

3, 4, 9 months: 79, 76, 70%

23

Alcohol abuse: Treatment groups 1, 2>3 at 3 months, but not at 6 months

1=2>3

0.5 and 1.5 year after completion of treatment (1 year and 2 years after initiation of aftercare)

22

No difference between treatments. In mental disorder, cognitive dysfunction 2>1 See matching report

2>1 mental disorder

3 years

23

1>2 dropout (3.7% vs 14%). Tend 1>2 quality of life and certain abuse measures, otherwise the same outcome

1=2

12 months, 95%

20

1. More often sober, stayed longer in treatment, higher reduction of compulsive symptoms Complete sobriety: 1. 58% 2. 27% 3. 30%

1>2=3

After completed treatment 86%

23

In inpatient care CBT, AA > standard treatment In outpatient care CBT > AA and standard treatment, respectively, concerning alcohol, social, and family situation and psychological problems

IP: 1=2>3 OP: 1>2=3

6, 12, 18 months after initiation of study

20

Positive change psychosocial functioning, mental symptoms, abuse. CBT > AA. Case management > AA. Change greater 12–18 months compared to 6–12 months

1>3 2>3

6, 12 months

22

No differences. Problems involving patient in treatment for abuse (few received treatment for abuse)

1=2


168


(cont.)

Study

Population

PS1

Treatment

Duration


N=139 96 men 43 women Antisocial personality disorder

2

1. Cognitive behavioral therapy patient only = 53 2. Relation enhancement cogn. = 86 (family members participate 4–8 sessions)

4–6 months + some booster sessions until 12 months = total 20 sessions

Teague [172] 1995

Focus severely mentally disturbed within 7 distr.

2

1. Team-specific working way including abuse fewer pat. (12/pers) 2. Traditional case management more patients (25/person)

27 months

1)



169

Followup


Outcome

Effect


22

No difference between treatments. Matching results: 1> 2 in antisocial personality disorder

1>2 pers. disorder

27 months

24

Team with special working method for severely mentally disturbed and who included abuse treatment better than traditional case management

170


Treatment of homeless abusers.

Study

Population

PS1

Treatment

Duration

Annis [7] 1979

N=70 Homeless men

3

1. Halfway house 2. Not halfway house

1. 4–8 months 2. Not in treatment

Braucht [22] 1995

N=323 15% women

3

1. Special unit for homeless abusers 2. Case management + 1

4 months

Burnam [26] 1995

N=276 84% men

3

1. Housing including intervention for abuse, mental disorder, n=67 2. As 1 but no housing support, more case management, n=144 3. No treatment

3 months intensive + 3 months further treatment when needed

Conrad [35] 1998

N=358 All men

3

1. Social model treatment home with CBT orientation + AA/NA + OP 2. Standard treatment: 3 w inpatient care + referral to different treatment units

1. 3, 4 months IP + 9 months OP 2. 2–3 w IP + 1 year OP

Cox [38] 1998

N=298 Homeless; 9% women

3

1. Intensive case management 2. Standard treatment

No time limit

Lapham [89] 1995

N=469 13% women

1. Intensive case management + 4 months sheltered housing (N=161) 2. Regular counseling + 4 months sheltered housing (N=164) 3. 4 months sheltered housing, no counseling (N=92) 4. Control group, no intervention

1–3: 67 days

Miller [108] 1975

N=20 All men

3

1. Behavioral therapy, contingency management 2. Standard treatment for homeless abusers

2 months

Ogborne [131] 1979

N=40 Homeless men

3

1. Counseling = 20 2. No treatment = 20 3. Ind. contact

Max. 6 months

1)



171

Followup


Outcome

Effect

3 months

14

Documented relapse to drinking 1. 51% 2. 46%

1=2

6 months

16

No difference concerning drinking pattern or use of services.

1=2

3, 4, 9 months: 79, 76, 70%

23

Alcohol abuse: Treatment groups 1, 2 >3 at 3 months, but not at 6 months

1=2>3

3, 6, 9, 12, 18 and 24 months 1. 60–77% 2. 47–54%

19

Trend to better outcome the first year, thereafter levelling out Alcohol consumption: days in past 30: Baseline 1. 19.0 2. 18.4 12 months 1. 5.7 2. 5.6 24 months 1. 7.3 2. 7.7

1=2

18 months; 82%

22

Small, but significant improvement in both drinking and social function 6 months: days with drinking (in past 30): 1. 14.6 (12.0) 2. 17.8 (11.1) (ES = 0.29)

1>2

10 months: 78%

19

Days with drinking in past 30 (10 months): (SD) 1. 5.3 (1.1) 2. 7.4 (1.1) 3. 7.1 (1.3) 4. 3.8 (1.9)

1=2=3=4

2 months; 100%

22

Alcohol-related arrests: median (SD) 1 2 Baseline 1.70 (1.15) 1.40 (1.07) 2 months followup 0.30 (0.48) 1.30 (0.81)

1>2

3 months 1. 16/20 = 80% 2. 12/20 = 60%

14

Only 10 in the intervention group had regular contact Numbers showing improvement not reported Improved situation tot. 3 patients

1=2


172


(cont.)

Study

Population

PS1

Treatment

Duration

Smith [161] 1995

N=149 All women

3

1. Environmental therapeutic community with supportive housing the first 3 months + 12-step treatment 2. Same as 1, but no supportive housing the first 3 months

3 months intensive treatment + 9 months low intensive

Smith [162] 1998

N=106, whereof 15 women

3

1. CRA 2. Standard treatment (12-step + work support, housing + psych

3 months

Sosin [165] 1995

N=418 26% women

3

1. Case management only (as aftercare after detoxification in IP) 2. CM + supportive housing 3. No aftercare

1. 3 months 2. 6 months

1)



173

Followup


Outcome

Effect

18 months from admission 90% followed up

22

No improvement in alcohol habits over time; no difference between groups No differences concerning housing and work

1=2

12 months

24

Alcohol consumption (drinks per week) median + SD at 12 months 1 2 35.59 (22.4) 46.67 (22.8)

1>2

12 months; 73.7%

19

Number of drinking days of past 30: 1 2 3 Baseline 17.8 16.9 16.4 12 months 4.8 4.3 6.8

1=2>3

174


Studies on therapeutic approach.

Study

Population

PS1

Treatment

Duration

Annis [8] 1983

N=150 Interns

2

1. Confrontation group = 100 2. No confrontation, traditional institutional care = 50

1=8 w

Kashner [82] 1992

N=137 Men

2

1. Rehabilitation increase selfconfidence, respect, tolerance, support = 72 2. Traditional confrontative program = 65 3. After IP, 1 year of aftercare

3–4 w IP 1 year aftercare

Miller [110] 1980


1

1. Bibliotherapy 2. Behavioral therapy, self control 3. 2 + relaxation training + social skills training 4. 2 + CBT broad spectrum

2–4: 6 w + 12 w

Miller [116] 1993


1

Therapist-style feedback on alcohol habit inventory 1. Confrontative 2. Client-centered 3. Waiting list

1 session


OP directly: N=952 685 men 267 women

2

1. Cognitive behavioral therapy, CBT 2. 12-step 3. Motivation enhancement therapy, MET

3 months 1, 2 = 12 sessions 3 = 4 sessions

2

Eight therapists were assessed: 1. Good interpersonal skill = (pat = 31) 2. Medium interpersonal skill = (pat = 47) 3. Low interpersonal skill = (pat = 47)

12 days

2

1. Multimodal behavioral therapy (MBT) 2. Dynamic structured (PT)

1 and 2 years respectively

IP before OP: N=774 619 men 155 women Valle [174] 1981

N=247 Majority men


1)



175

Followup


Outcome

Effect

12 months

19

No difference relapse between 1 and 2 12 interns with high self-esteem

1=2

6, 12 months after completion of IP Accomplishment IP 1. 90% 2. 95%

19

Outcome share of sober 6, 12 months: At 6 months: 1. 2.9 times more often sober than 2 At 12 months: 1. 2.1 times more often sober than 2

1>2

8 months assessment

21

Degree of empathetic ability was assessed according to empathy scale and was related to positive outcome for each therapist. 67 % of the variance of positive outcome was explained by good empathetic ability

1=2=3=4

12 months, 83%

26

Those who received client-centered feedback and saw abuse as a habit drank less than those who viewed abuse as an illness The more confrontation, the more resistance, more abuse. Followup

1=2>3

Through 1 year after completion of treatment In-between every 3rd month

27

In direct OP: Early alliance (therapist and patient) predicted participation in treatment, consumption during treatment and 12 months thereafter, after control other factors regardless of treatment After IP therapeutic alliance predicted share of sober days

6, 12, 18, 24 months

16

The higher interpersonal function in the therapist, the fewer number of relapses and days with less probability for use of alcohol at followup

Until 3 years after initiation of treatment

24

Early therapeutic alliance was better in MBT than in PT. Patient alliance positive association with different mood dimensions in MBT after 6 months, but not with course of abuse during treatment or 3rd year

1>2>3

176


Studies illustrating gender-related effects.

Study

Population

PS1

Treatment

Duration

Dahlgren [40] 1989

N=200 All women

1

1. Conversational treatment psychodynamic basis for women only IP + OP 2. Standard treatment IP + OP

Max. 8 months

Lapham [89] 1995


1. Intensive case management + 4 months sheltered housing (N=161) 2. Regular counseling + 4 months sheltered housing (N=164) 3. 4 months sheltered housing, no counseling (N=92) 4. Control group, no intervention (N=52)

1–3: 67 days

Robertson [147] N=37 1986 30 men 7 women

1

1. Motivation enhancing therapy 2. Cognitive behavioral therapy, control training

1. 3–4 sessions 2. 9 sessions 10 w OP

SanchezCraig [151] 1989


1


1. 3 sessions 2. 3 sessions 3. 6 sessions 3–6 w

SanchezCraig [152] 1991


1

Replication of S–C 89: 1. Brief counseling + brochure 2 pages 2. Brief counseling + manual 40 pages 3. Therapist + manual 40 pages

1. 3 sessions 2. 3 sessions 3. 6 sessions 3–6 w

1)



177

Followup


Outcome

Effect

Followup approx. 1 year after completed treatment (2 years from treatment start) 1. 75/100 = 75% 2. 68/100 = 68%

18

Improved drinking pattern: Year 1: 1 = 50/75 (67%), 2 = 31/68 (45%) Year 2: 1 = 44/75 (59%), 2 = 32/68 (48%)

Year 1: 1>2 Year 2: 1>2

10 months: 78% followup

19

Days with drinking in past 30 (10 months): (SD) 1: 5.3 (1.1) 2: 7.4 (1.1) 3: 7.1 (1.3) 4: 3.8 (1.9)

1=2=3=4

15.5 months, 89.2%

23

Alcohol consumption/month in units 1 2 Baseline 354.4 (53.4) 385.9 (65.6) Followup 268.9 (252.0) 129.4 (86.0)

2>1 Women better outcome than men

3 months (84%) 6 months (80%) 12 months (71%)

23

Days with heavy drinking: men 1 2 3 Admission 43 38 50 12 months 34 23 28 Days with heavy drinking: women 1 2 3 Admission 44 40 42 12 months 8 9 13

1=2=3

3 months (83%) 6 months (77%) 12 months (72%)

23


Women better outcome than men

1=2=3 Women better outcome than men

178


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1 Kolumnentitel

3

Pharmacotherapy for Alcohol Withdrawal Syndrome Johan Franck

3.1

Introduction

Withdrawal syndrome after discontinued consumption of alcohol is one of the criteria for the diagnosis of alcohol dependence. The condition is often without complications, but may progress to become a serious, and in some cases life-threatening, condition. Alcohol withdrawal symptoms can be classified into specific symptoms (withdrawal hallucination, delirium tremens or alcohol-conditioned psychotic syndrome, and generalized tonic-clonic seizures) and several unspecific symptoms (high pulse, elevated blood pressure, perspiration, tremor, agitation, anxiety, depression, etc.). The unspecific symptoms occur as early as a few hours after the blood alcohol level has started to decrease. The risk of seizures is greatest during the first few days after the cessation of alcohol intake, while delirium tremens usually develops after 3 to 5 days. Known risk factors for severe withdrawal syndromes and delirium tremens include concurrent physical illness, long-term intake of large amounts of alcohol, and a previous history of delirium or severe withdrawal syndromes. Hallucinations in association with alcohol intoxication and withdrawal usually pass spontaneously and will not be addressed further here, but they are a risk factor for developing delirium tremens. In treatment of withdrawal it is important to reduce the patient’s unspecific symptoms and subjective suffering, but the most important goal is to prevent seizures, delirium tremens, and death. Many studies have been published on the pharmacological treatment of alcohol withdrawal and delirium tremens. Most are studies of benzodiazepines, but other kinds of drugs have also been studied, e.g., anti-epileptics, alpha-2-agonists, beta-receptor antagonists, calcium antagonists, magnesium, antipsychotic drugs, and thiamine. The aim of this chapter is to present an overview of published clinical drug trials on withdrawal treatment for the respective groups of agents. Furthermore, recent meta-analyses in the area are summarized to compare the effectiveness of different agents in alleviating the symptoms of alcohol withdrawal and reducing the risk of withdrawal seizures and delirium.


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3 Pharmacotherapy for Alcohol Withdrawal Syndrome

3.2

Methods 3.2.1

Selection Criteria

A search was conducted for all prospective, randomized, double-blind trials with placebo control or comparison drugs. The effectiveness of antipsychotic drugs in alcohol withdrawal has been reported previously and is mentioned here only when other types of drugs are presented in the same study [104]. A few older studies which do not fulfill the selection criteria have been included in cases where recent documentation is deficient. 3.2.2

Diagnostic Criteria and Outcome Measures

Older studies often lack the diagnostic inclusion criteria presented in the DSM or ICD classifications. Nevertheless, such studies have been included. The most common outcome measure in the selected studies is the reduction of withdrawal symptoms, usually measured by a rating scale. The scale most often used is the Clinical Institute Withdrawal Assessment-Alcohol-revised (CIWA-Ar), a successor to the Gross Rating Scale for Alcohol Withdrawal [49, 118]. Other scales are presented in Table 3.1. Other outcome measures reported in some studies are the number of deaths and the number of cases of withdrawal seizures and delirium that occur during treatment. 3.2.3

Search Strategy

The search terms, “substance withdrawal syndrome/ethyl alcohol”, “alcohol withdrawal”, “psychosis, alcoholic”, and “substance withdrawal delirium” have been combined with “controlled trial” or “randomized controlled trial”. A specific search was made of “nitrous oxide” and “alcohol withdrawal”. The studies are divided below into two groups: treatment of alcohol withdrawal and delirium tremens, respectively. Quality scores are shown in Tables 3.1 and 3.2. The MEDLINE search covers the period from 1966 until 2000. Other databases searched were the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, the Cochrane Controlled Trials Register, PsychInfo, and SweMed. The reference lists from selected published reviews and primary studies were searched manually. No search was performed for unpublished studies.

3.3 Included Studies

3.2.4

Results

Eighty-two randomized controlled trials were found on drug treatment of alcohol withdrawal in clinical patient groups, i.e., patients who presented for care in hospitals or other health care facilities. The corresponding number of studies of delirium tremens was 13. Two of the studies fell within both of these categories and are therefore presented twice. Conclusions are presented for three meta-analyses of pharmacotherapy in alcohol withdrawal published since 1983. No meta-analyses addressing the treatment of delirium tremens were found.

3.3

Included Studies 3.3.1

Treatment of Alcohol Withdrawal

The neurophysiological background to withdrawal reactions after alcohol and drugs is largely known. Tolerance for, and physical dependence on, alcohol causes changes in the central nervous system which compensate for the suppressing effect of the alcohol on the excitability of the nerve cells, the conduction of nerve impulses, and the activity of neurotransmitters in the brain. When the intake of alcohol ceases, these changes cause a condition of increased excitability in the nerve cells, leading to the physical and mental symptoms which represent the withdrawal syndrome. Numerous medications and drugs have been tested for treatment of withdrawal syndrome (see Table 3.1). Clinical trials of the different groups of agents are summarized below. 3.3.1.1 Benzodiazepines (see Table 3.2a) Benzodiazepines compared to placebo Treatment with benactyzine is associated with fewer cases of delirium tremens than are other agents. Rosenfeld and Bizzoco reported that chlordiazepoxide yielded significantly more improved cases than placebo did [97]. The study by Wegner and Fink had deficiencies and was difficult to evaluate [123]. Oxazepam, chlordiazepoxide, and promethazine were all found equally effective for withdrawal symptoms and significantly better than placebo [20]. This finding was in contrast to Hekimian, who did not find any significant differences, but the number of patients was small [53]. Sereny and Kalant found chlordiazepoxide and promazine basically equally effective for tremor, perspiration, and sleep disorders [111]. Five cases of delirium tremens or withdrawal seizures occurred among those treated with promazine, but none in the group that received chlordiazepoxide. A study using an experimental design showed that chlordiazepoxide was superior to placebo for symptomatic treatment [109]. Lepola reported that patients subjectively experienced chlordiazepoxide to be more effective than tiapride, but no

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3 Pharmacotherapy for Alcohol Withdrawal Syndrome Table 3.1. Drugs tested for alcohol withdrawal, delirium tremens, and withdrawal seizures. Group of chemical agents

Indications

Generic name

Commercial names1

Benzodiazepines

Anxiety; agitation; alcohol withdrawal; status epilepticus

alprazolam

Alprazolam, Xanor

diazepam

Apozepam, Stesolid, Valium Librium Temesta Oxascand, Sobril

chlordiazepoxide lorazepam oxazepam Beta-carbolins Beta-receptor blockers

Calcium antagonists

abecarnil Hypertension; angina pectoris; myocardial infarction; migraine; tremor, etc.

Hypertension; vasospasm after subarachnoid hemorrhage

atenolol

Atenolol, Selinol, Tenormin, Uniloc

propranolol pindolol

Inderal, Propranolol Viskén

nimodipine

Nimotop

caroverine Diphenyl methylpiperazine derivatives

Urticaria; itch, agitation; alcoholism; senile agitation conditions

hydroxyzine

Atarax, Vistaril

Imidazoline receptor agonists

Hypertension; opiate withdrawal

clonidine

Catapressan

lofexidine Carboxamide derivatives

Epilepsy; alcohol withdrawal; neuralgia

chlormethiazole

Hermolepsin, Tegretol, Trimonil

Barbituric acid derivatives

Epilepsy; status epilepticus

phenobarbital

Fenemal

diemal

Veronal

Fatty acid derivatives

Epilepsy

valproic acid

Absenor, Ergenyl, Orfiril

Hydantoin derivatives

Epilepsy; status epilepticus

phenytoin

Epanutin, Fenantoin, Lehydan

3.3 Included Studies Table 3.1. (cont.) Group of chemical agents

Indications

Generic name

Commercial names in Sweden1

Proteinase inhibitors

Homeostasis in bleeding that is difficult to control or leakage of spinal fluid

aprotinin

Tisseel Duo Quick, Trasylol

Vitamin B

Conditions of deficiencies, e.g., anorexia, malabsorption, alcoholism

thiamine (vitamin B1)

Betabion, Benerva

Others

Delirium tremens; pre-delirium; alcohol withdrawal

chlormethiazole

Heminevrin

meprobamate tetrabramate caroverine metadoxine lithium

Litarex

Bipolar affective disorder Parkinson’s disease Anesthesia

1

bromocriptine lucidril propofol paraldehyde

Pravidel Diprivan

list not complete.

objective differences could be confirmed [70]. An attempt to simplify drug treatment of alcohol withdrawal has been described by Sellers: diazepam was administered in tablet form (20 mg) every hour until the patient’s symptoms had subsided (CIWA-A

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